Determining the Knowledge of Women and Their Attitudes Regarding Gynecological Cancer Prevention

The current study determines the knowledge of female course attendees of the "Municipality Cultural Center for Women", located in the city center of Sivas, Turkey, and their attitudes regarding gynecological cancer prevention. The participants of the study include 497 women attending one of the two Municipality Cultural Centers situated in the city center of Sivas. In this study, the sample was not selected; all participants were encompassed within the scope of our research. A total of 418 female course attendees who volunteered to participate in the research were identified as the sample. The data were collected during the months March-June 2011, by a questionnaire developed by the researchers. To compare the distribution of the collected data "Anova", "two independent t test examples" and "chi square test" were used. The research indicates that 45.1% of the women had had gynecological examination as a consequence of a physical disorder. The reason for 54.9% of the women to have gynecological examination is to have been scanned to check for gynecological cancer, 51.2% had a pap smear test. Some 34.9% of them had obtained information about cervical cancer, 39.7% via radio, television or internet and 36.3% from a doctor. Age, education level and marital status of the women participating in this study demonstrated statistically significant correlations (p<0.05) with gynecological examination and undergoing a pap smear test.

The health care services provided by nurses and obstetricians to maintain, sustain and advance the health status, have an important role on preventing gynecological cancer, on the early diagnosis of these diseases and the needs that may occur depending on the process of the disease.The role of nurses and obstetricians in providing the information and awareness about gynecological cancer is crucial (Lockwood-Rayermann et al., 2009;Ali et al., 2010;Savaş and Taşkın, 2011).

Materials and Methods
The current study determines the knowledge of the female course attendees of "Municipality Cultural Center for Women" located in city center of Sivas, Turkey and their attitudes regarding gynecological cancer prevention.The participants of the study include 497 women attending 6056 to one of the two Municipality Cultural Centers situated in the city center of Sivas.In this study, the sample is not selected; all participants are encompassed within the scope of our research.Four hundred eighteen female course attendees who volunteered to participate in the research have been identified as the sample.The data has been collected during the months March-June 2011, by a questionnaire developed by the researchers.In this form, there are questions concerning the age, educational status, marital status, profession, social security, type of the family and their knowledge about preventing gynecological cancer and their attitudes.Before the implementation of the questionnaire, the purpose of the research is explained to the course attendees and they orally consent to participate in this research.The data collected is analyzed by creating a database with the software package SPSS (14.0).To compare the distribution of the collected data "anova", "two independent t test examples" and "chi square test" have been used.

Results
One point seven percent of the women participating in this study are at the age of 18 and below, 18.4% are at the age of 45 and above, 84.4% are not working.32.1% of them are high school, 29.9% of them are elementary school graduates.Sixty seven-point nine percent of them are married.All of them have social security.Fourty sevenpoint eight percent of them identify their socioeconomical status as middle class.Fifty three-point one percent of the women have either 2 or 3 children, 66.8% gave a birth either 2 or 3, 70.3% had 1 miscarriage, 20.4% have 4 or more living children.Sixty nine-point two percent of the women have been using birth control methods, 30% of whom are using condoms, 25% are using the traditional method.Fifteen-percent 15% of the women are smoking cigarettes and none of them are using alcohol.Fourty-point nine percent of them exercise regularly.
One-point four percent of the women have had sexually transmitted infection, 24.6% have had gynecological infection.Among the women who have had gynecological examination, (58.4%), 45.1% of them had taken because of a physical disorder.After the last physical examination, 23.4% of the women have been diagnosed with infection, 95% of whom have been cured based on their diagnosis, the rest have not been treated since they found it unnecessary.The reason for 54.9% of the women to have gynecological examination is to have been scanned to check for gynecological cancer.Fifty-one-point two percent of them have had the pap smear test and 34.9% of them have got information about cervical cancer; 39.7% of whom have obtained the information via radio, television or internet, whereas 36.3% of whom have learned from a doctor.
It has been claimed by 88.8% of the participants that there is early diagnosis and cure for gynecological cancer, by 58.4% that the obesity and by 35.6% that the diabetes and the hypertension cause endometrium cancer, by 67.2% that never being pregnant or being pregnant at an older age leads to ovarian cancer, by 53.1% that beginning sexual relationship at an early age, getting pregnant three or more times at an early age cause cervical cancer, by 73.2% that lack of hygiene generates cervical cancer, by 67.7% that smoking cigarettes is a risk factor for gynecological cancer It has been declared by 68.4% of the participants that abnormal menstruation during menopause or after menopause are symptoms of cancer, by 66.6% that abnormal vaginal bleeding, pain during intercourse , the expanding stomach and having pain around stomach are the symptoms of uterus cancer, by 51.9% that yellow, dirty smelly, broth color without pain, brown color flows are the symptoms of cervical cancer, by 60.8% that having wound, feeling lumps by hand, itchiness, bleeding, having pain around outer genital area are the symptoms of vulvar cancer.
It has been declared by the 62.2% of the participants that the birth control pills reduce the risk of ovarian cancer, by 59.1% that menstruation between menstrual cycles, spotting after intercourse are not the symptoms of cervical cancer, by 51% that it is required to take Pap Smear test only if women have gynecological disorder, by 54.1% that diabetes, hypertension and obesity are not risk factors for outer genital cancer, by 41.4% that one should have gynecological examination when she has a gynecological disorder, by 47.6% that exercising regularly does not prevent gynecological cancer.It is determined that these women have incorrect knowledge.
It has been known by 67.7% of the women that it is required to reduce the stress and to use techniques for handling stress for preventing gynecological cancer, by 55.7% that it is necessary to avoid diets including excessive animal fat, by 70.3% that weight control is important, 51.4% that it is important to avoid tight underwear for preventing vulvar cancer (Table 1).
It has been found that the differences between the average points of the women is statistically significant according to their education level (p<0.05).While the average points of the high school graduates are 18.10±7.30,the average points of the elementary school graduates are 15.00±8.74.In the analyses, no differences have been discovered in the average points of the women according to their age groups, marital status, profession, social security type (p>0.05).
It has been found that the differences in having the pap smear test is statistically significant according to the age groups of women (p<0.05).When the women get older, they are more likely to have pap smear test and there is a significant difference compared to the younger ones having the test (Table 2).In the analyses, it has been found that the differences in having pap smear test is statistically significant according to their education level, marital status (p<0.05).While it is 34.6% for elementary school graduates to have had pap smear test, it is 34.1% for high school graduates.84.1% of the married women have had pap smear test, whereas only 15.9% of the single women have had the test.
It has been found that the differences in having the gynecological examination is statistically significant according to the marital status of the women (p<0.05).While 86.1% of the married women have gynecological examination, only 13.9% of the single women have had the examination.In the analyses, it has been found that DOI:http://dx.doi.org/10.7314/APJCP.2013.14.10.6055Determining the Knowledge of Women and Their Attitudes Regarding Gynecological Cancer Prevention the differences in having gynecological examination is statistically significant according to their education level, their ages (p<0.05).While 1.6% of the literate women have had the gynecological examination, 11.5% of women graduate of higher education have had the examination.The women who is 18 or below have never had gynecological examination whereas, 23% of the women who is 45 or above have had the gynecological examination.

Discussion
Gynecological cancer is a disease which can be prevented and cured when treated right.88.8% of the women in our study think that it is possible to have early diagnosis and to have been cured of gynecological cancer.In the study of Fallowfield et al. (2010) almost all of the women (99.4%) think that being scanned can reduce the risk of mortality and 96.2% think that being diagnosed with cancer after scanning may affect their prognosis positively.Additionally, for women to take advantage of having early diagnosis and to have the opportunity to be cured from cancer, their knowledge level on the risk factors of gynecological cancer and on the symptoms, protection and scanning is important.In the studies, the knowledge of women on gynecological cancer and early diagnosis is found to be insufficient (Eftekhar ve Yarandi, 2004, Kebede et al., 2011).However, knowing the risk factors about gynecological cancer is crucial for being cured and being protected.While it is known by more than half of the women that obesity, by almost one third of the women that diabetes and hypertension are risk factors for endometrium cancer, two third of the women know that never being pregnant or being pregnant at an older age are risk factors for ovarian cancer, more than half of the women that beginning sexual relationship at an early age, getting pregnant three or more times at an early age, lack of hygiene generate the risk factor for cervical cancer.
One third of the women in our study know the importance of being protected against sexually transmitted diseases for preventing cervical cancer.Sexually transmitted Human Papilloma Virus (HPV) is one of the factors causing cervical cancer which is accepted as the second most common reason for cancer deaths of women all over the world.In a study performed in Turkey about HPV prevalence, 23% of the women have been infected with HPV (Dursun et al., 2009).In the study carried out by Gil et al. (2010), women accept that HPV is a risk factor for cervical cancer.As for the study of Donders et al. (2009), while the women who indicate HPV as a reason for cervical cancer and know that for being protected it is important to be vaccinated was 50% in 2007, in 2008 it has reached to 80%.On the other hand, in different studies it has been determined that the level of women knowledge on the relation between HPV and cervical cancer is poor (Gil   , 2010;Rama et al., 2010;Paolini ve Arrossi, 2011).
The symptoms of Gynecological cancer, show differences according to the organ affected by the cancer.Therefore, it is possible to have early diagnosis by recognizing some symptoms of different types of gynaecological cancer.In our study, the two third of the women have knowledge of some symptoms of ovarian cancer, more than half have information about some symptoms of cervical cancer, 60.8% know some symptoms of vulvar cancer, 68.4% are aware of some symptoms of endometrium cancer.Additionally, a large group of them know that bleeding like spotting after instrumental sexual activities and intercourse is a symptom of cervical cancer.Despite it is known that unaccountable vaginal bleeding is a risk factor for cervical cancer, the symptoms of other cancer types may not have been known commonly (Phongsavan et al., 2010;Cooper et al., 2011).
More than half of the women in our study think that to be protected against gynecological cancer, handling stress, avoiding diets including excessive animal fat, weight control, exercising regularly are important.In "2008 Health Style Study" performed by Trivers et al. (2011) mention the importance of women being educated about the symptoms of gynecological cancer.Half of the women in our study know that it is important to use tight underwear for being protected against vulvar cancer, and it is possible to be protected against cervical cancer by vaccine.In a study performed 62% of the women consider vaccination as an option for preventing cervical cancer (Phongsavan et al., 2010).
In our study, while there is no statistical difference between the average knowledge points of the women about gynaecological cancer according to their socioeconomic (age, marital status, profession, social security) status, the study of Breitkoph et al. (2005) is important in the aspect that it shows the women with poor socioeconomic status have deficient knowledge on gynecological cancer (Breitkoph et al., 2005).In the study of Hawkins (2005), the level participants' knowledge, who are in the 18 to 34 age bracket with poor educational background and low income, on gynecological cancer is low.Similar to Hawkins study, our research indicates that the higher the education level of the women, the higher the average knowledge points related to gynecological cancer.
The methods developed for early diagnosis of gynecological cancer increases the success rate in its cure.Especially, the early diagnosis of cervical cancer is thought to be improved with the help of pap smear test (Phongsavan et al., 2010).Even though more than half of the women participating in our study have pap smear test, the percentage of the female university students in Gana having pap smear test is determined to be 12 (Abothchie ve Shokar, 2009).This percentage is quite low according to the results obtained by our study.
The studies indicate that women have lack of knowledge regarding the scanning tests, the frequency of having tests and the purpose of having the tests (Abothchie ve Shokar, 2009;Al-Sairafi, 2009;Nakaluvu, 2009;Phongsavan et al., 2010;Chigbu ve Aniebue, 2011;Cooper et al., 2011;Hawkins et al., 2011;Mbamara et al., 2011;Minchev et al., 2011;Paolino et al., 2011).More than half of the women in our study think that they should take pap smear test only when they have gynecological disorders.In a research related to the knowledge level and awareness of the women about pap smear and gynecological tests, 63.3% of the women think that pap smear test is done for the diagnosis of vaginal cancer, sexually transmitted diseases, uterus cancer and infections (Hawkins et al., 2011).In the study of Mbamara et al. (2011) it is determined that 85% of the women have not had the pap smear scanning test since they have never heard of it.In a study performed in Argentina about the comparison between the women who have had a scan for diagnosis of cervical cancer and who have not had, it is determined that 49% of the women who have had the test, and 73% of the women who have not had, have lack of knowledge on pap smear test (Paolini et al., 2011).
It is possible to reduce the lack of knowledge and false beliefs of women on the subject by widespreading the scanning programs.The pap smear test and routine examinations provide the women with the opportunity to be educated by the personnel of the health sector based on their needs.In our study, the relation between the women having pap smear test and having gynecological examination, and their getting older, becoming more educated and their marital status are found to be statistically significant.In many studies performed, the education level of the women is considered to be a factor affecting their average knowledge points on gynecological cancer (Breitkoph et al., 2005;Parker et al., 2006;Lacour et al., 2008).There are also studies indicating that there is a relation between the knowledge level, education, marital status and the age of the women regarding the prevention of cancer, and knowing about scanning tests for cancer and to have those tests (Al-Sairafi, 2009;Chigbu et al., 2011;Mbamara et al., 2011).The role of personnel in the health sector is very important for women to have information about gynecological cancer for protecting against it and improving the health.

Table 2 . The Distribution of having Pap Smear Test According to Their Age Groups
Asian Pacific Journal of Cancer Prevention, Vol 14, 2013 6058 et al.