https://imcjms.com Ibrahim Medical College Journal of Medical Science https://imcjms.com/registration/journal_full_text/473 Tue, 18 Jul 2023 11:54:35 +0000 Abstract Background and objectives: Developing screening programmes to lower breast and cervical cancer morbidity and mortality requires a better knowledge of psychological, socioeconomic, and environmental variables that may affect screening behaviours. This study was conducted to assess the knowledge, attitude and practices regarding breast and cervical cancer among women of reproductive age group in a village in West Bengal, India. Materials and methods: A descriptive type of observational study was conducted in village Muchisa of Budge-Budge II block, West Bengal among 300 women from January to June 2022 using a pre-designed, pre-tested, structured schedule by face-to-face interview method. Data were analyzed using SPSS version 25.0 using suitable descriptive and inferential statistics. Results: The mean age of the study participants was 31.6 ± 7.4 years. Out of 300 women, 41.7% and 41.3% had adequate knowledge on breast and cervical cancer respectively. Regarding attitude, 57.3% and 75.3% had highly favourable attitude on breast and cervical cancer respectively. Only 38 (12.7%) had performed breast self-examination at least once whereas only 5.3% had undergone Pap smear test at least once before the survey. Socio-demographic and economic factors of the respondents were significantly (p<0.05) associated with knowledge on breast cancer while none of these factors were found to have statistically significant association with knowledge on cervical cancer. Conclusion: Most of the study population did not have adequate knowledge of breast and cervical cancer, their risk factors and symptoms. Their attitude was positive but practice related to screening was very unsatisfactory. IMC J Med Sci. 2023; 17(2):011. DOI: https://doi.org/10.55010/imcjms.17.021 *Correspondence: Vineeta Shukla, Senior Resident, Department of Community Medicine, Institute of Post Graduate Medical Education and Research, Kolkata, India; Email: vineeta1992@gmail.com   Introduction Globally, breast and cervical cancers are the most common cancer among women. There were about 2.3 million new cases of breast cancer worldwide and about 685 000 deaths from this disease in 2020 [1]. The burden of breast cancer is expected to increase to over 3 million new cases, and 1 million deaths every year by 2040. Likewise, there were about 570,000 new cases and 311,000 deaths of women from cervical cancer globally in 2018 [2]. It is evidenced that, approximately 83% of the world’s new cases and 85% of all cervical cancer deaths reported are from developing countries [3]. Age standardized incidence rate of breast cancer in India is about 25.8 per 100,000 women that means roughly 1 in 4000 females are affected [4]. According to Globocan data 2020, breast cancer accounted for 10.6% (90,408) of all fatalities in India and 13.5% (1,78,361) of all cancer cases, with a cumulative risk of 2.81[5]. The mortality rate is lower in developed countries compared to developing countries due to availability of early cancer screening programmes. The established risk factors for breast cancer include early menarche, late menopause, late pregnancy, oral contraceptives, and hormone therapy for menopause. The main risk factors for the human papillomavirus (HPV), which causes cervical cancer, include being single, being illiterate, having antibodies against the herpes simplex virus (HSV), smoking, parity and having several sex partners [6]. Breast cancer unlike other type of cancers, is an easily screenable cancer, affects an easily visible organ and has an effective treatment. One of the major causes of low survival rate among breast cancer patients in developing countries is late diagnosis, and delay in initiation of effective treatment. Early diagnosis is aided by early reporting of patients to the health care set-up which can only be possible by creating awareness about the early detection of clinical symptoms and signs. Breast self-examination (BSE) helps in early detection of breast cancer. But, several studies have reported low or inadequate knowledge and practice of BSE among women of developing countries [7-12]. Similarly, several studies have reported low state of knowledge on cervical cancer as well as practice of cervical cancer screening among rural and tribal women in India [13,14]. Improving understanding of psychological, socio-economic, and environmental factors that may influence screening behaviour is a critical element of developing screening programs to reduce breast and cervical cancer morbidity and mortality. The success and benefits of screening to control and prevent breast and cervical cancer depend to a great extent on the level of awareness of the women of reproductive age group. With this background, the present study was conducted to assess the knowledge, attitude, and practice regarding breast cancer and cervical among women of reproductive age residing in a village of Budge-Budge II block, West Bengal, India. The study also attempted to find out the association (if any) between knowledge of breast and cervical cancers and socio-demographic and other epidemiological factors.   Materials and methods This descriptive type of observational study with cross sectional design was conducted among women of reproductive age residing in Muchisa village of Budge-Budge II block, West Bengal which is the rural field practice area of Institute of Post Graduate Medical Education and Research, Kolkata. The study period was from January to June 2022 (6 months). The study was initiated after approval from the institutional Ethics Committee (Approval letter no. IPGME&R/IEC/2022/244 dated 18.04.2022). Women of reproductive age, aged 15-49 years, who were permanent resident of that area for more than 1 year, were selected as study population. Women who did not give informed written consent were excluded from the study. Sample size was calculated using the following formula: n=(Z² *pq)/d2, where n=sample size, Z=1.96 (for Confidence interval = 95%), p=58% (prevalence of adequate knowledge regarding breast cancer from Singh et al. study)[8], q=1-p, d=relative error 10% and Non-Response=10% Hence, putting the values in the equation: n=278 + 10% of 278 = 306 The study participants were selected from the list maintained at the sub-centre by simple random sampling. The schedule had the following sections: 1.   Socio-demographic information of the respondents, 2.   Information on the knowledge, attitude, and practice regarding breast and cervical cancer. The schedule was prepared in English and later translated into Bengali (local language) by a language expert and retranslated by an independent expert. It was then pretested among 20 randomly selected women from the same setting to assess its clarity, validity, and reliability. After some minor modifications, the schedule was revaluated by the experts. The participants who were included in pretesting were excluded in the final study sample. After a brief introduction about the study and its importance, informed written consent was obtained. Data were then collected by face-to-face interview method. Investigator assured the participants that their identity and the information they provided would be treated as confidential. A maximum of 3 visits were made to every house to minimize drop out. The study variables were broadly dependent variables (knowledge, attitude and practice regarding breast and cervical cancers) and independent variables (socio-demographic characteristics such as age, religion, level of education, occupation, socio-economic status as per Modified BG Prasad Scale 2022 [15], type of family, etc). The forms were checked for completeness. Knowledge of breast cancer was assessed on 7 questions. Each correct response was scored one while incorrect/do not know was scored zero. Range of knowledge scores was zero to seven. The 75th percentile score (4) was taken as cut off. Those scoring 4 and above were categorized as having adequate knowledge. Attitude on breast cancer was assessed on 4 items on a 5-point Likert scale (responses ranging from strongly willing to strongly unwilling). The range of scores was 4 to 20. Respondents scoring 17 (Median) and above were said to have highly favourable attitude. The study participants were asked if they had undergone breast self-examination ever. Those who responded “yes” were said to have satisfactory practice. Seven questions were used to assess knowledge on cervical cancer. Each accurate response was given a score of 1, while wrong or do not know responses were scored 0. Scores on knowledge ranged from 0 to 7. The cut off was set at the 75th percentile score (3). Those who received a score of 3 or higher were considered to have adequate knowledge. Four items on a 5-point Likert scale measuring attitude towards cervical cancer were employed (responses ranged from highly willing to strongly unwilling). Scores ranged from 4 to 20. Respondents who received a score of 16 or higher were considered to have a highly favourable attitude. The study participants were questioned if they had ever undergone a Pap smear test. Those who replied "yes" were considered to have satisfactory practice. Data were tabulated into Microsoft Excel 2019 (Microsoft Corp, Redmond, WA, USA) and then imported to Statistical Package for the Social Sciences (SPSS for Windows, version 25.0, SPSS Inc., Chicago, USA) for interpretation and analysis. Descriptive and inferential statistics for study variables were performed. Pearson’s Chi square test was applied to test association between knowledge of breast and cervical cancer and socio-demographic variables. A p value of less than 0.05 was considered statistically significant.   Results The study was conducted among women of reproductive age group between 15-49 yrs of age Among the 306 participants contacted at their homes; data was available from 300 participants with 98% response rate. The mean age of the study participants was 31.6 ± 7.4 years and 87.3% were Hindus. Out of the total study participants, 92% were married and 81.3% were homemakers. Of the total, 29% and 26.7% had completed higher secondary and secondary level education respectively. About 45% belonged to lower middle socio-economic class according to Modified BG Prasad Scale 2022 and most of them were living in joint families (67.7%). Only 8.7% of the study participants were having past or family history of breast cancer. All the study participants had heard the terms breast cancer and cervical cancer. A large percentage of subjects (77.3%) were aware that breast cancer is one of the most prevalent cancers in women but only 30% could correctly coin that its occurrence increases with increasing age, 33% women said that breast cancer exhibits a hereditary pattern and 71.7% of them said that it is curable if detected early (Table-1). A mixed result was found in knowledge regarding breast self-examination. Only 17.3% respondents had knowledge of BSE and only 38 (12.7%) had performed BSE beforehand. Interestingly, friends and relatives were the most common source (31) of knowledge about BSE. Only 14 women got knowledge from health workers (Table-1). About 81% of the women were willing to know more about breast cancer, 46.3% were strongly willing to visit a doctor if they felt any lump in their breast, all (100%) were willing to do BSE regularly if they were shown how to do it and all of them were willing to share this knowledge with their friends of similar age (Table-1).   Table-1: Distribution of the study population according to their knowledge, attitude, and practice regarding breast cancer (n=300)     Out of 300 participations, 133 (44.3%) could correctly point out at least one symptom of breast cancer and 132 (99.2%) respondents indicated presence of any lump or tumor in the breast as a symptom of breast cancer. However, there was less knowledge regarding any risk factors for breast cancer as only 25.3% (76/300) could correctly name one of them. The knowledge regarding risk factors of breast cancer among the study-population was maximum for tobacco/smoking (58, 76.3%), followed by alcohol (56, 73.7%) and least for exposure to radiation (6, 7.9%) (Table-2).   Table-2: Distribution of the study population according to their knowledge on symptoms and risk factors of breast cancer     The risk factors of breast cancer currently present among the study participants were long term use of OCPs (9.3%), followed by obesity (BMI >30.0) (4%). Only 2 had history of exposure to radiation (Table-3).   Table-3: Distribution of the study population currently having risk factors of breast cancer (n=300)*     It was found that nearly half (49.0%) of the study participants recognised cervical cancer as a major public health problem. Only 33 (11%) could name at least one symptom correctly, 35 (11.7%) could say at least one risk factor and 13.3% responded ‘yes’ when asked if HPV was a causative agent of cervical cancer. More than half (56.7%) said that cervical cancer was preventable and 64% said that it could be cured if detected early (Table-4). Only 25 (8.3%) had knowledge about Pap smear and only 5.3% had undergone the test, at least once, on their own. Out those who knew about Pap smear test, most of them heard it from health care workers (19/25), followed by friends and relatives (8/25). About 87.3% were willing to know more about cervical cancer and 66% were inclined towards visiting a doctor if they noticed any post-menopausal bleeding or abnormal vaginal discharge. Around 60% were willing to undergo Pap smear test but the rest 40% were not sure (Table-4).   Table-4: Distribution of the study population according to their knowledge, attitude, and practice regarding cervical cancer (n=300)     The knowledge regarding symptoms of cervical cancer depicted by the study population was bleeding after menopause (32), persistent blood-tinged vaginal discharge (31) and foul-smelling vaginal discharge (28). None of the study participants were having any symptoms pertinent to cervical cancer. Out of the 35 participants who could name the risk factors of cervical cancer, 35, 30 and 24 respondents identified multiple sexual partners, sexually transmitted diseases and family history of cancer respectively as the (24) (Table-5).   Table-5: Distribution of the study population according to their knowledge on symptoms and risk factors of cervical cancer     The mean knowledge score on breast cancer was 2.99 ± 1.63, median score was 3 and 75th percentile score was 4. About 41.7% of the study population had adequate knowledge on breast cancer. The mean attitude score on breast cancer was 16.65 ± 0.62 and median score was 17. About 57.3% had highly favourable attitude (Table-6 and 7).   Table-6: Range of scores and central tendency measures of knowledge, attitude, and practice regarding breast and cervical cancer among the study population (n=300)     The mean knowledge score on cervical cancer was 2.14 ± 1.54, median score was 2 and 75th percentile score was 3. About 41.3%% of the study population had adequate knowledge on cervical cancer. The mean attitude score on cervical cancer was 16.07 ± 0.79 and median score was 16. About 75.3% had highly favourable attitude (Table-6 and 7).   Table-7: Distribution of the study population according to their knowledge, attitude, and practice regarding breast and cervical cancer (n=300)     Age group, marital status, occupation and socio-economic status of the respondent were significantly associated with knowledge on breast cancer (Table-8). None of the socio-demographic factors were found to have statistically significant association with knowledge on cervical cancer (Table-9).   Table-8: Association between knowledge regarding breast cancer and socio-demographic variables (n=300)     Table-9: Association between knowledge regarding cervical cancer and socio-demographic variables (n=300)     Discussion Most cancer patients in India usually seek medical advice when the disease is in an advanced stage. This may be attributed to lack of awareness on various screening programmes. This study attempted to assess the knowledge and attitude of reproductive age group women on breast and cervical cancer as these two are the commonest cancers occurring amongst Indian women. Along with this, presence of various self-reported risk factors was also documented. Gangane et al. from their study from Wardha district in rural Maharashtra reported that about 63% of the study participants were aware of breast cancer [14]. This was greater than the present study findings where 41.7% had adequate knowledge on breast cancer. Very high proportions (89%) of women were reported aware of breast cancer in Trichy, Tamil Nadu India [9]. BSE is an inexpensive, simple, noninvasive method for early detection of breast tumors. Thus, knowledge about this procedure and consistent practice can impede severe morbidity and mortality due to breast cancer. Only 52 (17.3%) of the study participants in the current study knew of BSE which was strikingly unusual and was a matter of concern. In Prathipadhu, Guntur, Andhra Pradesh almost 70% of the respondents had not heard of BSE [10]. Around 62.5% of the women did not have any idea of the procedure of BSE in Trichy, Tamil Nadu [9]. On the contrary, Baburajan et al [11] in their study in rural Ramanagara district in Karnataka reported that 85.1% of respondents had never heard of BSE which is a significantly lower proportion that the current study. In the present study, only 38 (12.7%) women responded that they perform BSE. In Tamil Nadu, BSE was practiced by 18% women and out of them, only 5% participants practiced it regularly every month [9]. In Karnataka study, less than 10% of women had ever performed BSE [11]. A very small proportion of the participants reported practicing BSE at least once in Maharashtra study (3.45%) [12]. About 97.5% were willing to approach a doctor in case of presence of lump/abnormality in their breast in Trichy as reported by Kumarasamy et al [11] which was lower than this study (100%). In the present study, all of the study participants were willing to do BSE regularly if they were taught about the technique while the response was 83% in Tamil Nadu study [9]. Oral contraceptive pill usage was found as the most prevalent risk factor for breast cancer in the present study. However, other similar studies on breast cancer mentioned only about the awareness of risk factors among the study participants and not regarding the presence of risk factors. Over 99% had not heard about Pap smear in a study in Tripura, India by Banik et al [13]. In the present study, 91.7% had never heard Pap smear test before. The respondents in Tripura did not undergo any screening test for cervical cancer citing absence of symptoms as the main reason. About 5.3% of the women in this study reported undergoing Pap smear test. According to Ghosh et al [14] in a study among tribal women in Karnataka, 82.9% of the participants said they had heard of cervical cancer, only 2.3% were aware that it could be detected early and only 51% knew that it could be prevented. However, 99.9% were in favour of cervical cancer screening. None of them had undergone screening for cervical cancer.   Limitations The study was conducted in only one village of a large block thus limiting the generalization of the findings. Also, some of the respondents may have given socially favourable answers. Inclusion of a health education intervention followed by post test among the study participants would have been better.   Conclusion Most of the study participants did not have adequate knowledge of breast cancer and cervical cancer,its risk factors and symptoms. Their attitude was positive but practice related to screening was very unsatisfactory. Knowledge and practice regarding breast self-examination and Pap smear test were poor. Age group of the study population, occupation and family history of cancer were found to have statistically significant association with knowledge on breast cancer. More awareness programmes stressing on screening methods including availability of HPV vaccine should be carried out, especially in rural areas.   Acknowledgement The authors would like to thank the Block Medical Officer, Auxiliary Nurse Midwife (ANM) of Muchisa Health and Wellness centre and all the respondents for their active participation and support in the study.   Authors’ contribution KR, VC, MB and VS equally involved in Concept devlopment and design of the study, analysis and interpretation of data, drafting and revising and final approval of the manuscript.   Financial support Nil   Conflict of interest There are no conflicts of interest.   References 1.     Arnold M, Morgan E, Rumgay H, Mafra A, Singh D, Laversanne M, et al. 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