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A Study on Knowledge and Awareness of Cervical Cancer Among Females of

Rural and Urban Areas of Haryana, North India

Article in Journal of Cancer Education · February 2020

DOI: 10.1007/s13187-020-01712-6

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Journal of Cancer Education
https://doi.org/10.1007/s13187-020-01712-6

A Study on Knowledge and Awareness of Cervical Cancer

Among Females of Rural and Urban Areas of Haryana, North India
Lokesh Kadian 1 & Gulshan Gulshan
3
& Shivkant Sharma
1
& Indu Kumari
1
& Chetna Yadav
1
& Smiti Nanda
2
&
Ritu Yadav 1

# American Association for Cancer Education 2020

Abstract
Lack of awareness of screening methods, risk factors, and symptoms may lead to late diagnosis and poor prognosis of cervical
cancer. The plan of this study was to assess the level of awareness about cervical cancer and HPV vaccine among females of rural
and urban areas of Haryana, India. This cross-sectional study was performed using a comprehensive self-designed questionnaire
on 1500 women of urban (700) and rural (800) background aged 18–65 years, evaluating their knowledge for cervical cancer and
screening, HPV infection and its preventive measure, and symptoms and risk factors. Data obtained was analyzed and interpreted
by using simple percentages and bar charts. Most of the participants were aged between 21 and 30 years and had college level
education. Majority of the women from rural areas had poor knowledge about cervical cancer (55%) and its screening (75%),
HPV infection (87.5%), and HPV vaccine (95%) compared with urban areas. Knowledge about symptoms and risk factors was
very low in both rural and urban areas. Whatever little knowledge the women had about cervical cancer was from college
education, friends, neighbors, relatives, and medical practitioner or doctors. The survey pointed to the critical need to educate
women about cervical cancer and its early diagnosis, related risk factors, symptoms, and preventive measures which can be
achieved by launching extensive awareness programs for educating females about cervical cancer in India.

Keywords Cervical cancer . Awareness . Knowledge . Screening . Rural . Urban . Women

Introduction
Cancer of the cervix is a major burden on women’s health
worldwide. Compared with developed countries where the
implementation of cytology-based screening programs in the
1940s greatly reduced incidence rate, cervical cancer is still
the second important cause of cancer-related deaths among
women in developing countries like India [1]. Cervical cancer
is diagnosed in more than 120,000 females in India, of which
67,000 die from the disease every year and this represents
cases which are recorded because these women could seek
medical help, but if we consider rural areas where people do
* Ritu Yadav
yritu3757@gmail.com
1
Department of Genetics, Maharishi Dayanand University,
Rohtak, Haryana 124001, India
2
Departments of Obstetrics and Gynaecology, PGIMS,
Rohtak, Haryana, India
3
Department of Biosciences and Bioengineering, IIT Bombay,
Mumbai, Maharashtra, India
not have access to advanced diagnosis and take those into
consideration then the data must be horrifying [2]. In the
world, about 25% of all cervical cancer deaths occur in India
where the incidence is very high among women in rural areas
and low socio-economic status [3]. The most common cause
of a higher rate of mortality due to cervical cancer in India is
lack of awareness about its symptoms, risk factors, screening
programs, and preventive measures.
The most common symptoms of cervical cancer are ab-
dominal pain, before and after intercourse bleeding, persistent
back pain, urinary urgency, white vaginal discharge, smelly
vagina, etc. [4]. Infection with human papillomavirus (HPV)
is the most important risk factor associated with cervical can-
cer. HPV is very common worldwide and primarily transmit-
ted through sexual contact in both males and females [5]. The
relationship between HPV and cervical cancer is well studied
and 70% of cervical cancer cases are associated with HPV
infection. Additional risk factors include multiple sexual part-
ners, sexual intercourse at an early age, prolonged use of oral
contraceptive pills, early age at first pregnancy, multi-parity,
multiple abortions, and smoking [6]. While the HPV infection
is the major risk factor for the development of cervical cancer,

vaccination with HPV vaccine confers protection against cer-
vical cancer.
Early detection and treatment of cervical cancer will help in
reducing the number of deaths. Most studies have also shown
that the survival rate of a person is improved if cervical cancer
is diagnosed and treated at earlier stages [7]. But in India, most
cases are diagnosed at later and last stages which reduce the
survival rate. The main reason for late stage diagnosis of the
cancer is a lack of awareness and availability of screening
methods. In developed countries, regular screening programs
such as Papanicolaou (Pap) smear, visual inspection of the
cervix with acetic acid (VIA), and HPV DNA test for precan-
cerous lesions reduced the incidence and mortality of cervical
cancer, but in developing countries, cervical cancer screening
and prevention programs have failed to meet their objectives
due to financial, social, and logistical problems [8].
Unfortunately in India, implementation of screening programs
for cervical cancer is still not possible due to lack of awareness
and misconceptions about gynecological diseases, and lack of
national cervical cancer screening programs [9].
There is a great need for a nationwide government-
sponsored public health policy on the prevention of cervical
cancer by early diagnosis or vaccination, or both. Women with
low levels of knowledge about cervical cancer and its early
screening and prevention are less likely to reach screening
services. Therefore, the present study aims to evaluate the
understanding and awareness of cervical cancer and its screen-
ing and prevention in females of rural and urban areas of
Rohtak City, India.
Materials and Methods
Ethical Permission
Ethical approval for conducting this study was obtained from
the Institutional Human Ethical Committee (IHEC) of
Maharishi Dayanand University, Rohtak, India, with
Number IHEC/2019/79.
Study Design and Population
A survey was conducted from 1st January 2016 to mid of
June 2018 on1500 female participants belonging to rural
(800) and urban (700) areas of Haryana, India, using pre-
validated questionnaire. The women participants enrolled in
this study were from different age groups ranging from 18 to
65 years and had a varied educational background. All partic-
ipants were requested to fill the questionnaire. Evaluation of
awareness about cervical cancer was done based on answers
given by participants to the questions.
J Canc Educ
Inclusion and Exclusion Criteria
Women between the age of 18 and 65 years, who gave consent
for face to face interview, were included in the study.
Individuals who had never heard of cervical cancer and cor-
related cervical cancer with cervical pain (osteoarthritis) and
did not give consent for participation in the study were ex-
cluded. Women who did not want to answer the questions
were also excluded from the study.
Questionnaire Design
A pre-validated questionnaire containing 20 questions was
prepared after extensive research to get detailed information
from the participants. The questionnaire was based upon the
general questions related to knowledge of cervical cancer, its
symptoms and risk factors, and knowledge of HPV infection
and HPV vaccine. We also included questions about the edu-
cational status of women and their main sources of obtaining
information.
Data Collection
Random sampling was done to represent the women popula-
tion in Haryana. After the random face to face interviews of
female participants, each questionnaire was checked to con-
firm its appropriate completion by supervisors. All the ques-
tions were in English but were translated into Hindi and local
languages to help the women to understand the questions cor-
rectly. Verbal informed consent was obtained from all the
study participants.
Statistical Analysis
Answers for the individual question were recorded and data
was analyzed using Microsoft Excel and GraphPad Prism 8
software (GraphPad, La Jolla, CA, USA). The data is
expressed in percentage frequencies, means, and standard de-
viations. Statistical analysis to compare knowledge between
rural and urban areas was done by using Fisher’s exact test. A
p value of less than 0.05 was considered statistically
significant.
Results
Sociodemographic Characteristics of Enrolled
Individuals
The participants in this study were grouped into two catego-
ries based on their background, i.e., rural (800) and urban
(700). Table 1 shows the sociodemographic characteristics
of study population. The mean age of the rural participants
J Canc Educ

Table 1 The sociodemographic

characteristics of enrolled Sociodemographic characteristics Rural (800) Percentage (%) Urban (700) Percentage (%)
individuals of rural and urban area
Age
≤ 20 170 21.25 190 27.14
21–30 270 33.75 243 34.71
31–40 120 15 79 11.29
41–50 78 9.75 90 12.86
≥ 51 162 20.25 98 14
Education
No formal education 98 12.2 50 7.1
Primary 149 18.6 128 18.4
Secondary 193 24.2 134 19.1
College 360 45 388 55.4
Marital status
Married 446 55.75 340 48.6
Unmarried 354 44.25 360 51.4
Profession
Student 350 43.75 270 38.57
Housewife 270 33.75 200 28.57
Working 180 22.5 230 32.86

was 33.06 ± 14.20 (median was 28 and age range between 21
and 65 years) and that of urban participants was 31.44 ± 13.16
(median was 26 with age range of 18 to 60 years). Most of the
enrolled participants from the rural and urban background
were between age group 21 and 30 years (33.75% and
34.71% respectively) and had some sort of college education
(45% and 55.4% respectively). About half of the enrolled
women in both rural (44.3%) and urban (51.4%) regions were
unmarried as shown in Table 1.
Cervical Cancer Knowledge and Its Screening
In our study group, most known cancers were breast cancer
and lung cancer. In rural areas, only half of the participants
(49.7%) had ever heard of cervical cancer, but even among
those, they were not sure whether it is female-related cancer
or found in males. Knowledge about cervical cancer (20%)
and screening test such as Pap smear (18.75%) is very low.
More than half of the women participants (66.25%) were
not willing to go for cytological testing as shown in
Tables 2 and 3.
Whereas in urban areas, more than half of the women
(57.1%) had heard of cervical cancer and also knew that only
women are affected by cervical cancer. Women belonging to
urban areas were almost 25% more likely to know about cer-
vical cancer (p = 0.004) and willing to undergo cytological
screening (p = 0.0023). The number of participants with
knowledge about cervical cancer (34%) and Pap screening test

Table 2 Basic questions for

cervical cancer knowledge and its Questionnaire item Rural % Urban % OR (95% CI) p value
screening among rural and urban
areas Have you heard about cervical cancer 0.74(.61–0.9) 0.004*
Yes 398 49.7 400 57.1
No 402 50.2 300 42.9
Do you know that only females are 0.46(0.38–.57) 0.0001*
affected by cervical cancer
Yes 234 29.25 330 47.14
No 566 70.75 370 52.85
Do you think that you should undergo 0.72 (0.58–0.89) 0.0023*
cytological examination
Yes 270 33.75 290 41.5
No 530 66.25 410 58.6

OR, odd ratio; CI, confidence of interval

*p > 0.05
 J Canc Educ

Table 3 Knowledge about cervical cancer and its screening, HPV neighborhood/relatives who consulted a doctor or were diag-
infection and vaccination and the source of information
nosed with cervical cancer as shown in Table 3.
Knowledge Rural % Urban % p value

Knowledge about cervical cancer Knowledge of Cervical Cancer Symptoms

Poor 440 55 252 36 0.0001*
Satisfactory 200 25 210 30 We asked participants for their knowledge of the signs
Good 160 20 238 34 and symptoms of cervical cancer. The numbers of those
Knowledge about Pap test who answered for each item are presented in Table 4. The
Poor 600 75 290 41.42 0.0001* most commonly known symptoms in rural individuals
Satisfactory 50 6.25 250 35.71 were pain and bleeding during or after sexual activity
Good 150 18.75 160 22.85 (30.25%), painful and irregular menstruation (26.62%),
Knowledge about HPV discomfort during urination, and pain in pelvis
Poor 700 87.5 500 71.43 0.0001* (20.25%). The most known symptoms in urban individ-
Satisfactory 50 6.25 100 14.3 uals were painful and irregular menstruation (34.43%) and
Good 50 6.25 100 14.3 unusual smelly discharge from the vagina (32.71%).
Knowledge about HPV vaccine Women who lacked formal education could identify only
Poor 760 95 650 92.85 0.0009* two to three symptoms. Lack of knowledge of cervical
Satisfactory 30 3.75 20 2.85 cancer is reflected in poor understanding of symptoms.
Good 10 1.25 30 4.3 In both rural and urban areas, women were aware that if
Source of information about cervical cancer any symptoms appear then they should undergo gyneco-
Television 122 30.7 142 35.4 6.57 logical examination (40%) and include regular physical
Newspaper/magazines 152 38.2 180 45 exercise (28%) in their routine.
Medical practitioner 177 44.5 204 51
Friends/neighbors/relatives 199 50.1 200 50
Internet 76 19 120 30 Knowledge About Risk Factors
Education 279 70 320 80
Knowledge about cervical cancer risk factors in women is
*p > 0.05 assessed in both rural and urban areas. In this survey, we
found that almost all women were well aware of the risk
(23%) was also higher than in rural areas as shown in. In urban factors but they were not fully aware that these risk fac-
areas, 41.5% of female participants were ready to go for cy- tors are related to cervical cancer. In the rural area, the
tological testing, while more than half of female participants most commonly known risk factors were multiple sexual
were not ready for it as shown in Tables 2 and 3. partners (23.75%), and long-term use of oral contracep-
In our study group, knowledge about HPV infection and tives (23.25%) and intrauterine devices (22.12%). In ur-
HPV vaccination was very low in both rural (6.25% and ban areas, the most commonly known risk factors were
1.25% respectively) and urban (14.3% and 4.3% respectively) early onset of sexual activity (28.57%), smoking (28%),
areas. The source of information for knowledge and aware- and obesity (27%). The least known risk factors in both
ness and its screening in both rural and urban area was mainly rural and urban areas were HPV infection and poor
from school/college level education, followed by friends/ menstrual hygiene. Women were also poorly educated

Table 4 Knowledge about

symptoms among rural and urban Symptoms Rural % Urban %
area
Painful/irregular menstruation 213 26.6 241 34.42
Pain/bleeding during or after sexual activity 242 30.3 153 21.86
Weight loss 122 15.3 64 9.14
Itching in genital area 140 17.5 81 11.57
Leg pain 81 10.12 71 10.14
Back pain 97 12.12 64 9.14
Constant fatigue 156 19.5 134 19.14
Discomforting urination 162 20.25 148 21.14
Pain in the pelvis 162 20.25 155 22.14
Unusual/smelly discharge from vagina 118 14.75 229 32.71
J Canc Educ

Table 5 Knowledge about risk factors among rural and urban area cancer by early diagnosis. In the USA and Canada, the reduc-
Risk factors Rural % Urban % tion in the incidence of cervical cancer and the subsequent
reduction of the female mortality rate are attributed to the
Early start of sexual activity 158 19.75 200 28.57 widespread introduction of the Pap smear screening program
Multiple sexual partners 190 23.75 178 25.42 as a secondary preventive measure for early detection of cases.
Early pregnancy 166 20.75 170 24.29 The level of awareness in different studies was 94% in Greece,
Repeated pregnancy 126 15.75 147 21 80% in Taiwan, and 53% in Bhutan [14–16]. In our study, the
HPV infection 50 6.25 100 14.29 number of participants was higher who did not think to under-
Smoking 174 21.75 196 28 go cytological examination for early screening of cervical
Being overweight 157 19.62 189 27 cancer; this may be due to lack of knowledge about the im-
Having a weakened immune system 169 21.12 155 22.14 portance of Pap test. Furthermore, knowledge about Pap
Long term use of oral contraceptives 186 23.25 147 21 smear test in both rural (18.75%) and urban (22.85%) areas
Intrauterine devices 177 22.13 78 11.14 is very poor in the present study. If there is little information
Having a family history 126 15.75 117 16.71 about cervical cancer, we cannot expect good knowledge
about screening programs like Pap smear test and HPV test
in these women.
about preventive measures such as HPV vaccines (1.25% Less than half of the female participants were able to rec-
and 4.3%) as shown in Table 5. ognize the signs and symptoms but women were not sure if
these symptoms were related to cervical cancer. The most
recognized symptoms in our sample population were irregular
Discussion and painful menstrual bleeding, persistent and abnormal vag-
inal discharge, and bleeding after sexual intercourse.
Cervical cancer is one of the most frequent malignancies in According to women, occasional symptoms such as white
women worldwide, accounting for 17% of all cancer deaths in discharge, pelvic pain, and smelly vagina are normal, occa-
women between 30 and 69 years of age [10]. Despite being sionally, and are not a major headache for them so they do not
curable and preventable if diagnosed at early stages, cervical feel any need to consult a gynecologist for these symptoms.
cancer still causes more than 67,477 deaths per year in India This non-seriousness of females towards symptoms is mainly
which is mainly due to lack of awareness, screening programs, due to lack of awareness, about the severity of the disease, and
and intervention approaches [2]. This study sheds light on the hesitation to discuss.
current awareness level about cervical cancer, screening, Early start of sexual activity, smoking, being overweight,
symptoms, and risk factors in rural and urban areas of multiple sexual partners, and early pregnancy were most rec-
Haryana, India. ognized risk factors in urban areas while multiple sexual part-
In our study group, despite the fact that the majority of ners, long-term use of oral contraceptives, intrauterine de-
women were educated and working, only half of them in both vices, and smoking were most recognized by rural women.
rural (50%) and urban (57%) areas had heard about cervical A previous study in Thailand mentioned that 81.8% and
cancer. While approximately 71% women in rural areas did 85.6% of respondents knew that first sexual intercourse at a
not know that it was a female-related cancer, half of the urban young age and having multiple sexual partners were risk fac-
women were aware of it. These results were found highly tors for cervical cancer. Despite the introduction and associat-
significant in both rural and urban areas (p < 0.05). ed promotion of the HPV vaccine in 2008, awareness of HPV
Awareness about cervical cancer in both rural and urban areas as a risk factor was also very low in both rural (6.25%) and
is very poor, which is a major concern for halting early screen- urban (14.3%) areas of our study population. After witnessing
ing, diagnosis, and treatment of cervical cancer. A previous a lack of knowledge about the risk factors, women’s thinking
study conducted in rural parts of India reported that only 38% seems oblivious to the risk factors that contribute to the devel-
of people knew that cervical cancer is the most common can- opment of cervical cancer.
cer [11]. A study done among the nursing staff in Central India In the present study, knowledge regarding vaccination is
reported that 86% were aware of cervical cancer and in an almost negligible in both rural (1.25%) and urban (4.3%)
another study done in Pondicherry, it was reported that 45% women. Despite being the higher prevalence of HPV16 and
were aware of cervical cancer and only 3% of people were 18 in Haryana, the knowledge about HPV as the major risk
aware of HPV vaccination [12, 13]. This shows that even factor and its treatment is almost negligible. Also, medical
primary health care workers had very poor knowledge about guidance and awareness programs are almost non-existent in
cervical cancer and the HPV vaccine. our study population and mainly in rural areas. Before intro-
Cytological screening, such as a Pap smear, will help in duction of the HPV vaccine in the National Immunization
reducing both the incidence and mortality of invasive cervical Program, there is a need to decrease the cost and duration of

vaccine use [17]. Thus, an effective vaccination program
based on regional epidemiological profile of HPV will help
in reducing the cervical cancer burden in women of Haryana,
India.
Training of nurses and local workers, seminars in rural
schools and colleges, and making local panchayats, social
workers like Anganwadi and ASHA workers, women repre-
sentatives, and dispensaries aware about cervical cancer will
further help in educating all the women. There is a need to
arrange for routine screening test all over India, as a preven-
tive measure is always better. Various study models have em-
phasized that early detection and cure is economically better
than putting manpower and funds in later stages when cancer
has already spread. Unlike other cancers in case of cervical
cancer, we have a great advantage of early detection with
routine screening, so efforts should be made to use it appro-
priately and save precious lives. We should learn from other
countries which have greatly reduced their share of cervical
cancer–related deaths by adopting regular screening ap-
proaches and HPV vaccination.
Acknowledgments We would like to thank Hanisha, Nitu Sharma,
GeetanjaliSinghal, and Nagma Ansari for their assistance during survey.
We also like to thank all participants enrolled in the study.
Compliance with Ethical Standards
Ethical approval for conducting this study was obtained from the
Institutional Human Ethical Committee (IHEC) of Maharishi Dayanand
University, Rohtak, India, with Number IHEC/2019/79. All data collect-
ed from human participants in the study were according to the ethical
standard of the Institutional Human Ethical Committee.
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