Understanding and Responsiveness Level about Cervical Cancer and its Avoidance among Young Women of Pakistan

Cervical cancer is a malignant neoplasm arising from cells originating in the cervix uteri (Turkistanli et al., 2003). One of the most common symptoms of cervical cancer is abnormal vaginal bleeding (Berraho et al., 2012), but in some cases there may be no obvious symptoms until the cancer has progressed to an advanced stage (Kumar et al., 2007). Treatment usually consists of surgery (including local excision) in early stages, and chemotherapy and/ or radiotherapy in more advanced stages of the disease (Farhath et al., 2013). The global burden of cervical cancer is 500,000 cases every year (Tas et al., 2010), with 270,000 women dying of it globally that is one death every two minutes (Ferlay et al., 2001; Schoueri-Mychasiw et al., 2013). Approximately 80 per cent of deaths related to cervical cancer occur in developing countries such as Pakistan (Moosa et al., 2014). Typically in Pakistan and Asia, a woman would be susceptible to this cancer from marriage to onwards, with commencement of sexual relations (Sankaranarayanan, 2009).


Introduction
Cervical cancer is a malignant neoplasm arising from cells originating in the cervix uteri (Turkistanli et al., 2003).One of the most common symptoms of cervical cancer is abnormal vaginal bleeding (Berraho et al., 2012), but in some cases there may be no obvious symptoms until the cancer has progressed to an advanced stage (Kumar et al., 2007).Treatment usually consists of surgery (including local excision) in early stages, and chemotherapy and/ or radiotherapy in more advanced stages of the disease (Farhath et al., 2013).
The global burden of cervical cancer is 500,000 cases every year (Tas et al., 2010), with 270,000 women dying of it globally that is one death every two minutes (Ferlay et al., 2001;Schoueri-Mychasiw et al., 2013).Approximately 80 per cent of deaths related to cervical cancer occur in developing countries such as Pakistan (Moosa et al., 2014).Typically in Pakistan and Asia, a woman would be susceptible to this cancer from marriage to onwards, with commencement of sexual relations (Sankaranarayanan, 2009).
A study published in 2008 by GLOBOCAN, a WHO project for cancer-related research, reveals that in Pakistani women, cervical cancer incidence is 19.5 per 100,000 in 2008 as compared to less than 9 per 100,000 in 2002 (a clearly rising trend).The same study shows deaths from the cancer at 12.9 per 100,000 (Ferlay et al., 2010).Risk levels for young girls are much higher today than before (Demirtas and Acikgoz, 2013).Pakistan has in fact moved from a low risk to a moderate risk country for cervical cancer and the increasing incidences are seen especially in younger women with the disease at an advanced stage when they go to the doctor for diagnosis.(Khan et al., 2007).
Cancer screening using the Pap smear can identify precancerous and potentially precancerous changes in cervical cells and tissue (Ozkahraman and Yildirim 2012).In developed countries, the widespread use of cervical screening programs has dramatically reduced the incidence of invasive cervical cancer (Canavan and Doshi, 2000).
Cervical cancer is one of the most preventable cancers afflicting the female population (Akinyemiju, 2012) .The development of Human Papilloma Virus (HPV) testing and vaccination are expected to contribute greatly in curbing the potential disease process (Munoz et al., 2004;Villa et al., 2006).Human Papilloma virus (HPV) infection appears to be a necessary factor in the development of almost all cases (90+%) of cervical cancer (Kumar et al., 2007;Ghojazadeh et al., 2012).HPV vaccines that are effective against the two strains of this large family of viruses that currently cause approximately 70% cases of cervical cancer have been licensed in the U.S, Canada, Australia, and the EU (Lowy and Schiller, 2006).Since the vaccines only cover some of the cancer-causing (highrisk) types of HPV, women should seek regular Pap smear screening, even after vaccination (HPV vaccine, 2008;Hong et al., 2013).
Typically, early cervical cancer is asymptomatic, but abnormal vaginal bleeding can occur, once the cancer becomes invasive (Petignat and Roy, 2007).Cervical cancer is the second most common cancer among women and the third leading cause of cancer deaths among women globally in low-resource settings (Zhao et al., 2012), affecting women at a time of life when they are critical to social and economic stability (Goldie et al., 2005).Causal role of infection with high risk Human Papilloma Virus (HPV) strains in cervical cancer has been targeted in the past two decades (Chen et al., 2012).A number of Primary and Secondary preventive approaches have been developed to prevent and treat infection with HPV (Wheeler, 2007;Raychaudhuri and Mandal, 2012).
This study was conducted with an aim to know about the awareness level of young Pakistani women related to any field of study or profession about cervical cancer and to educate them about this deadly disease of females as well.The purpose of this study was to describe the knowledge and beliefs about the cervical cancer.Our findings are useful in facilitating the formulation of realistic public health strategies that are synchronized with women's cultural upbringing, psychological responses, and preferences.

Experimental design
A cross-sectional, interview-based survey was conducted from May 2013 to March 2014 in Punjab (province of Pakistan).A questionnaire, having twenty questions was designed, out of which, 14 questions were close ended, and 6 questions were of open ended type.

Study population
Female population of three educational sectors (medical, non-medical professionals and public which included uneducated persons) from different cities of Punjab participated in this survey.

Sample size
On total 1100 survey questionnaires were distributed out of which 873 individuals responded, only female subjects were included in the study.

Data collection tools and analysis
Questionnaire was designed, based on study objectives, taking help from the previous literature and studies available on the topic added with content specific questions.The questionnaire was divided into two main parts, first dealing with the demographic profile of subjects and second consisted of the questions regarding the knowledge and awareness about different aspects of cervical cancer.

Statistical analysis
Microsoft Excel and SPSS 16 were used for organizing the collected data obtained from the survey.

Ethical considerations
The respondents were assured of the confidential nature of this survey, and were given the right to hide or show their names upon their own wish.

Results
Women from different fields e.g.medical, pharmacy, dentistry, physiotherapy, veterinary, nursing, business studies, mass communication, sociology, economics, and other professions e.g.house wives and teachers took part in this study.Uneducated labor, field workers, house maids, and villagers were also included in this study after simplifying questions in easy and understandable language  1).
Out of all the respondents (873), just 254 (29.1%) individuals responded as if they know about the term "cervical cancer".Out of this (29.1%), the share of medical professionals is 7.1% (62/873), non-medical but educated individuals have a share of 15.5% (135/873) and only 57 uneducated females were aware of this type of cancer (Table 2, Figure 1).
Those who knew about cervical cancer term, only 35/254 (13.8%) medical professionals were aware about its exact location in the body, while some of the other individuals also pointed the right option.Overall (including medical, non-medical and un-educated respondents), 15.4% females identified this cancer as the cancer of breast, 29.1% as cancer of cervix, 26% as cancer of abdomen and 29.5% as cancer of vagina.
24% of the respondents who have heard about cervical cancer from all fields said HPV is the causative agent, 21.6% recognized poor hygiene as the cause and 16.1% considered unprotected sex as a root cause of cervical cancer.While 38.2% do not have any knowledge about the cause (Table 2).
18.1% (of the population who claimed to be familiar with cervical cancer) answered correctly as Pap smear test for diagnosis of cervical cancer, 24% respondents were not aware of proper diagnostic measures while 57% individuals had no idea about the diagnosis of this disease (Table 2).
From our studies we got to know that only 38 individuals out of all the respondents were vaccinated against this disease, majority of which was from medical profession (Table 3).
Overall 28.3% respondents have absolutely no idea  about the treatment and prevention methods against the disease.While the rest of the respondents who knew at least about this cancer indicated some sort of treatments like surgery (17%), medication (19.7%) and vaccination (78.7%).Out of all the respondents, 1.6% individuals had family member or a closely known individual suffered from cervical cancer (Table 3).Pakistani women do not have enough knowledge about the danger of this disease, but just superficial information about the disease.14.6% of the total surveyed population had some sort of knowledge about the disease, while the rest of the population do not have any clue about this disease by any means of knowledge sharing, interview, literature, media or some other means.(Table 4).
Overall 15.7% considered illiteracy as a major reason behind ignorance about the knowledge of disease, 14% individuals considered the reason of busy routine, 23.5% specified as unawareness about its dangerous and alarming effects, 29% respondents indicated the reason behind, is the shy nature of the women to discuss about such diseases.While 18% individuals stated lack of resources and poverty as the reason behind the ignorance of information about this deadly disease (Table 4, Figure 2).
Upon further, the respondents claimed that our media is not playing enough role to create the awareness about the disease (93.%) and even government is not playing its active role for creating the awareness about this disease in public (91.5%).Besides the cultural, economic  and social limitations, all the respondents appreciated the role of women in creating the awareness about the disease by means of face to face discussion with peers (23.%), by means of social networking websites and other electronic communication methods e.g SMS (17%), and by conducting active discussions as well as educational sessions at institutional level (11.8%).Majority of the respondents (47%) are in the favor of all these roles by the women to create awareness about the disease (Table 5).
In our survey questionnaire, the respondents were asked to give their suggestions about the awareness creating activities.14.5% of the respondents suggested conducting the awareness creating campaign in hospitals.14.4% suggested to on-air talk shows on TV and radio.27% suggested the distribution of health bulletin and its explanation through lady health visitors, while 44% suggested to adopt all these means to create awareness in public about this deadly disease (Table 6).

Discussion
The majority of respondents in our survey were unable to recognize cervical cancer as a dangerous public health problem.Only about a 41% of the professionals interviewed were able to correctly identify cervical cancer as being the most common gynecological cancer, as also reported for India (Lee et al., 2007).
It was clear from our findings that the participants' knowledge on cervical cancer and HPV is inadequate.Majority of the respondents were unaware of the term cervical cancer.Pitts and his colleague also reported that majority of women surveyed had less or no information about what cervical cancer was (Pitts and Clarke 2002).
Another study regarding the assessment of level of knowledge about cervical cancer was conducted in Nunavik, Quebec in which 175 women were interviewed, also indicated less or no proper awareness about Cervical Cancer (Cerigo et al., 2012).
Another study to assess the knowledge and awareness about Cervical Cancer and its prevention amongst interns and nursing staff was conducted in tertiary care hospitals in Karachi, Pakistan.This study showed that out of 400 subjects interviewed 23.4% correctly recognized that cervical cancer is the most common malignancy in gynecological cancers, while 52.0%thought that it's moderately common and 23.3% thought that it is least common (Ali et al., 2010).
As the studies by Bhurgi and his colleagues, almost same types of results have been observed in our findings for example, huge percentage of those who were aware of the term were unable to identify the body part where this cancer takes its roots.Some women considered it as a cancer of uterus and some thought it as a cancer of breasts, a few correctly identified it as a cancer of cervix.The respondents who answered correctly about the causative agent were mostly from health related fields, respondents who were from the fields other than health sciences had little to no idea about causative agent.Most of the respondents considered poor hygiene and unsafe sexual practice as risk factors.Only a few percentages were aware of the vaccine and the importance of being vaccinated (Bhurgi et al., 2007).
The most disappointing point of this survey was the fact that in the view of all respondents' media and government are playing no role and that is the basic reason why Pakistani women are unaware about such a deadly disease.Majority of women considered shyness and illiteracy a reason for this ignorance.
Almost all female students were of the view that government should organize seminars in educational institutes as a part of awareness programs which is also suggested by Giles andGarland in 2006 (Giles andGarland, 2006).
The results of this study reflect fact that the young women of Pakistan are not aware to a satisfactory level about this deadly disease of female genital tract.In this study a fact has come to the surface that females who are from bio sciences related field knew more about cervical cancer but females from other fields had virtually no idea about this deadly disease which can kill any women.A great percentage of women are not aware of diagnosis, treatment, prevention etc. which is certainly alarming.It is therefore imperative to create awareness in all the urban and rural areas of Pakistan to save our women from this easily preventable devastating disease.Media and Government authorities must start awareness programs.Syllabi that are taught in schools colleges and universities must be updated with such health issues.In a year, one day must be celebrated as cervical cancer day.Moreover the cost of vaccine, facilities for the diagnosis must be maintained at an affordable level.Those women who are aware of this disease should play their active and positive role in educating other females in their circle.When this issue will be raised at individual and national level we shall be very soon be able to have a strong control over the prevalence of this disease.
A pleasing outcome of this survey was to make all the women agree to play their role in creating awareness about cervical cancer.They will pass on what so ever knowledge they have gained about this disease to all the women they know.This is to be done either by sending them emails, text messages or verbally.DOI:http://dx.doi.org/10.7314/APJCP.2014.15.12.4877Understanding and Responsiveness about Cervical Cancer and its Avoidance among Young Women of Pakistan

Figure
Figure 1.A Comparison of Awareness Level of the Respondents, with Respect to Education (Educated or Uneducated), and Field of Education (Medical or Non-Medical)

Figure
Figure 2. Possible Reasons behind the Ignorance and Awareness of Disease

Table 4 . Knowledge of Respondents about Familiarity of Reason behind Ignorance of Disease, Media Playing any Role, Government Playing any Role and Have you Shared Knowledge with Other
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.12.4877Understanding and Responsiveness about Cervical Cancer and its Avoidance among Young Women of Pakistan