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AWARENESS ON CERVICAL CANCER-RISK ASSESSMENT

Objective: To create awareness on cervical cancer, a level of knowledge about cervical cancer, to be advised of effective screening procedures based on their risk assessment, to educate about preventive measures after screening. Methods: This is a prospective questionnaire-based survey conducted by providing materials such as patient information leaflets, video clips and posters and educating the public regarding the disease from 1st January 2016–30th June 2016 i.e. for a period of 6 mo. Results: Knowledge was provided by using pictures, presentations, and patient information leaflets. Out of 1000 population, the respondents 762 (76.2%) females and 200 (20%) males were aware of cervical cancer. Among the 48 women who attended the screening, 23(47.9%) were identified with various symptoms and are on treatment. Out of these, 3 members were diagnosed positively and level of knowledge has increased significantly after creating awareness. Conclusion: Primarily health care professionals such as nurses and pharmacists should also be educated in various aspects to upgrade their knowledge as it was observed that their level of knowledge was relatively low. Clinical pharmacist in this regard has a major role to play in up lifting and improving the quality of life of the patient.


INTRODUCTION
Cervical cancer is the second most common cancer in women worldwide, with over 90% of cases occurring in developing countries. Most of the cases and deaths are seen in developing countries and India attributes to about 15% of the cancer deaths in the world mostly in rural areas. A persistent infection with a highrisk oncogenic human papillomavirus (HR-HPV) is involved in almost all cases [1]. HPV infection is very common in young women with early sexual activity, with a peak before 25 y, usually without clinical consequence. In nearly 10% of cases, this infection persists and is associated after 5 to 10 y with lesions that may regress, remain stable or progress to a higher grade and invasive cancer. Evolution of cervical intraepithelial neoplasia (CIN) to invasive cancer is slow, about 10 to 20 y for an immunocompetent woman. This slow progression allows an effective secondary prevention based on screening and treatment of precancerous lesions, using cervical cytological testing according to Papanicolaou (Pap smear or Pap test), visual inspection of the cervix with 3-5% acetic acid (VIA), or more recently HPV DNA testing. Immuno-suppression, especially due to human immunodeficiency virus (HIV) infection, is a predisposing factor for persistent infection with HR-HPV and the development of squamous intraepithelial lesions (SIL). High HIV viral loads and low CD4 counts are associated with a higher risk of HR-HPV infection and cervical abnormalities. The risk of recurrence or progression of cervical lesions is 4-5 times higher in women living with HIV. Infection with one of the 15 HR-HPV genotypes is significantly more common in HIV-infected women, while the distribution of low-risk oncogenic HPV is not affected by HIV status [2,3]. This reflects a higher propensity of HR-HPV in determining persistent infections. A vaccine called Gardasil has been developed that protects against the two high-risk HPV types (types 16 and 18), which cause 70% of cervical cancers in women and 90% of all HPVrelated cancers in men five. It also protects against two low-risk HPV types (types 6 and 11), which cause 90% of genital warts. Gardasil is used in the school-based national HPV vaccination program. Another vaccine called Cervarix is available, which protects against the same two high-risk HPV types (types 16 and 18). It does not protect against low-risk HPV types which cause genital warts. Over 187 million doses of Gardasil have been given safely, in over 130 countries around the world [4].

MATERIALS AND METHODS
A community-based Prospective self-questionnaire survey to create awareness among the public about cervical cancer and, advice for effective screening, lifestyle modifications, prevention among the public was conducted for a period of 6 mo from January to June in Guntur.

Materials
Consent form, Data collection form-I, Data collection form-II, Awareness aids-Patient information leaflets, Posters, Multimedia, Questionnaire forms-I and II, Risk assessment questionnaire, Feedback form.

Inclusion criteria
All men and women aged above 14yrs for awareness.

Exclusion criteria
Women with total hysterectomy. Women with a positive history of cervical cancer.

Plan of work
The work was planned to carry out accordingly as follows.
To include people satisfying the criteria, we had designed a patient data collection form and a questionnaire form to collect all the data required for the study which helps to create awareness on cervical cancer about its screening procedures, risk factors, lifestyle modifications and prevention by circulating leaflets, visual presentation, oral and poster presentation to motivate the women for the effective participation in the screening program. We had also collected feedback about the awareness after creating awareness had enlightened the study.

Study method
The study was conducted in Guntur. A pilot study was conducted for the readability and understanding of the questionnaire and patient information leaflet. A data collection form was developed in which all the details of the patients are noted. Patients were given adequate knowledge on cervical cancer. Subjects were provided with patient information leaflets on cervical cancer. Patients, as well as illiterates who did not wish to participate in the study, were also be provided with help of patient information leaflets and videos. A self-administered questionnaire was given to the subjects who have given their willingness to participate in the study. A risk assessment questionnaire was distributed to the subjects after assessing the self-administered questionnaire. Risk assessment to the subjects who were married, completed family or patients with a positive family history. Risk assessment was done by using an online risk assessment tool and patients shall be informed as to what level they were at risk. Patients were advised for effective screening procedures. Consent was taken from subjects who underwent screening. Patients who understood that they were at risk were advised for screening which was further conducted by the physician and counseled about their lifestyle modifications. A feedback form was distributed randomly to find out the better outcomes of the study. The difference in the knowledge levels was observed. The data was analyzed using a descriptive analysis, Likert's scale, Chisquare, and P-test [5].

Ethical approval
Ethical approval was taken with a no.10 from Guntur Medical College.

Risk assessment
No epithelial abnormalities were observed candidial cervicitis. Between the ages group of 40-50 a total of 2(4.1%). Among 50-60 y of age group, 1(4.1%) were observed with both dysplastic squamous epithelial cells and squamous cell carcinoma differentiated, while in 60-70 age group also identified with the same number i.e., 1(4.1%) was known to be squamous cell carcinoma undifferentiated [11,12].

DISCUSSION
Out of 1000 population, the respondent's 762 (76.2%) females and 200 (20%) males are aware of cervical cancer ( fig. 1, 2). Among males, 60 were married and 120 were unmarried. Among all these, 459 members belong to the age group of 16-20 y. The highest population belongs to the age group of 16-20 y as the maximum population included in the study was students. The age group of 20-30 y consists of 188 members, 106 members belong to the class of 30-40 y, 120 members belong to the age group of 40-50, 117 members belong to the age group of 50-60 and 10 members belong to the age group of 60-70 (table 1) (table 2). The highest illiteracy rate is seen in married women [13].
Regarding the level of awareness, out of 1000 members, 405 members (40.5%) belonging to the science field have said that they heard about cervical cancer and 595 members (59.5%) answered that they don't know about cervical cancer. Most the population i.e. 595 members (59.5%) belongs to the non-science background answered that they don't know about the causative organism whereas, 405 members (40.5%) belongs to the science background answered that they know about the causative organism of cervical cancer. Out of 1000, 595 members (59.5%) are not aware of the HPV vaccine whereas, 405 members (40.5%) were aware of HPV vaccine (table 3 and 5) [14].
Regarding the level of satisfaction, 372 members (37.2%) are very satisfied, 318 members (31.8%) were extremely satisfied and 310 members (31%) were moderately satisfied with the matter explained. Much of population i.e. 534 members (53.4%) are very satisfied, 214 members (21.4%) were extremely satisfied, 202 members (20.2%) were moderately satisfied, and 50 members (5%) were slightly satisfied with the information provided. Most population i.e. 548 members (54.8%) were extremely satisfied, 283 members (28.3%) were very satisfied and 169 members (16.9%) were moderately satisfied with the information provided on cervical cancer ( Out of these members, 410 members were married and 595 members were unmarried [17]. Regarding the knowledge of risk factors for cervical cancer, the maximum number of population (30%) has answered that sex at an early age is the major risk factor for cervical cancer. 20% of the population had answered that weakened immune system is the risk factor. The population of 20% had answered that it is due to multiple sexual partners. The 15% of population believed that long-term use of oral contraceptives is the major risk factor whereas, 10% had answered that it is due to infection with HPV and remaining 5% of the population had answered that the major risk factor is having many children and not going for regular screening ( fig. 5).
It was also observed that most of the population have understood about the risk factors and symptoms associated with cervical cancer. Out of 1000, 595 members are not aware of the HPV vaccine whereas, 405 members were aware of HPV vaccine ( fig. 6).
Among all the respondents 500 (50%) females and 340 (34%) males had chosen radiation, chemotherapy, and dietary changes were the treatment options for cervical cancer.
Among all the respondents 493 (49.3%) females and 400 (40%) males, 1% had agreed that safe sexual practice, 1% had agreed that physical activity and 40 members (4%) had agreed that diet was the lifestyle modifications to be followed.
There are several barriers to the uptake of screening which includes lack of information on cervical cancer, cancer screening is painful, fear of vaginal examination, not allowed by culture religion, lack of female screeners at the facility, and screening is expensive, long distance to the hospital. Among the females 353, 48 (13.5%) have attended to the screening. certain symptoms such as vaginal discharge 3(6.2%), post-coital bleeding 2 (4.1%), menstrual irregularities 9(18.7%), postmenopausal bleeding 6(12.6%), hormonal imbalances 11(22.9), other complaints such as PCOS, Infertility, back pain, lower abdominal pain 17 has been observed (table 9) [19].

CONCLUSION
There are significant differences between the knowledge levels before and after creating awareness among the study population. It was also observed that most of the population have understood about the risk factors and symptoms associated with cervical cancer.
Regarding the level of awareness, out of 1000 members, 405 members (40.5%) belonging to the science field have said that they heard about cervical cancer and 595 members (59.5%) answered that they don't know about cervical cancer. Many the population i.e. 595 members (59.5%) belongs to the non-science background answered that they don't know about the causative organism whereas, 405 members (40.5%) belongs to the science background answered that they know about the causative organism of cervical cancer. Out of 1000, 595 members (59.5%) are not aware of the HPV vaccine whereas, 405 members (40.5%) were aware of HPV vaccine.