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J Edu Health Promot 2019,  8:216

Challenges of health promotion and education strategies to prevent cervical cancer in India: A systematic review

1 Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India
2 Institute for Medical Epidemiology, Biostatistics and Informatics, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
3 Research Triangle Institute Global India Private Limited (RTI International), New Delhi, 100 037, India; International Agency for Research on Cancer (IARC/WHO), Lyon CEDEX 08, France

Date of Submission18-Mar-2019
Date of Acceptance13-Jul-2019
Date of Web Publication29-Nov-2019

Correspondence Address:
Dr. Jissa Vinoda Thulaseedharan
Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Medical College PO, Trivandrum - 695 011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_156_19

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BACKGROUND: Although there is a reduction in cervical cancer incidence over the years, it keeps the second position of the most common cancers among females in India. The aim of this review is to understand the challenges of health promotion and education strategies to prevent cervical cancer in India.
MATERIALS AND METHODS: This review is based on 78 studies published during 1993–2017 on the topics of awareness, attitude, and acceptance toward cervical cancer, screening, and human papilloma virus vaccination among Indians. The extracted information was summarized according to different populations such as people from different social and community groups, women and men attended clinics, students (nursing/medical/nonmedical), health-care providers (doctors, nurses, and other health workers), migrated Indians, and cervical cancer patients.
RESULTS: The awareness about cervical cancer and its prevention was very poor among women from different communities and the majority had a negative attitude toward screening and vaccination in general. The health professionals and medical students were more aware of cervical cancer and its prevention compared to the general population. Majority of students irrespective of medical or nonmedical background had a positive attitude toward vaccination. Only a small proportion of women in the general population were ever screened.
CONCLUSIONS: Observations from this review indicate immediate attention of the public health authority to take appropriate actions to educate and motivate general population toward cervical cancer prevention and to improve the facilities to incorporate the much needed preventive and early detection interventions in India.

Keywords: Cervical cancer, India, prevention and control

How to cite this article:
Thulaseedharan JV, Frie KG, Sankaranarayanan R. Challenges of health promotion and education strategies to prevent cervical cancer in India: A systematic review. J Edu Health Promot 2019;8:216

How to cite this URL:
Thulaseedharan JV, Frie KG, Sankaranarayanan R. Challenges of health promotion and education strategies to prevent cervical cancer in India: A systematic review. J Edu Health Promot [serial online] 2019 [cited 2020 Jan 26];8:216. Available from: http://www.jehp.net/text.asp?2019/8/1/216/271911

  Introduction Top

Cervical cancer is a long-term and rare outcome of persistent infection with one of the common oncogenic type human papillomavirus (HPV) infections.[1] One or more of the symptoms such as vaginal discharge, sometimes foul-smelling, irregular bleeding, postcoital spotting or bleeding, and postmenopausal spotting or bleeding are the symptoms of early-stage cervical cancer followed by urinary frequency and urgency, backache, low abdominal pain, kidney failure, and even more severe symptoms in later stages.[2]

Cervical cancer prevention includes primary, secondary, and tertiary level activities. Health education and vaccination against HPV infection are components of primary prevention, whereas secondary prevention focuses on early detection.[2] Early diagnosis and screening are the two components of early detection. Early diagnosis helps to identify and treat at an early stage in symptomatic women when having a better prognosis, whereas screening identifies precancers in asymptomatic women before they progress to invasive cervical cancer.[3] Diagnosis, management, and palliative care are part of tertiary prevention.[2]

Globally, one out of every five incident cervical cancer patients is from India.[4] The recent report of the global burden of disease study shows that cervical cancer incidence declined from the first position in 1990 to the third position in 2016 among all cancers in India and the Globocan 2018 shows that still, cervical cancer is in the second position of the most common cancers among women in India.[5],[6] Although there is a reduction, the incidence of cervical cancer in rural India is still high compared to other parts of India.[7],[8],[9] In addition, the differences in quality and accessibility of health services make a wide variation in cervical cancer survival in India.[10],[11],[12]

Quadrivalent and bivalent prophylactic HPV vaccines are licensed in India, but socio-cultural issues, high cost as well as the negative arguments precludes the implementation of HPV vaccination through the national immunization program in India.[13],[14] However, the states of Delhi and Punjab initiated routine vaccination of 12-year-old girls a few years back as part of their immunization program.[15] The Pap smear, visual inspection with acetic acid (VIA) and HPV testing with opportunistic screening are available in India, particularly in urban areas, but the vast majority of women have never been screened in India.[14] Tamil Nadu and Sikkim are the two states implemented cervical cancer screening through primary care services in India.[16]

In this context, we reviewed to understand the challenges of health promotion and education strategies to prevent cervical cancer in India through the level of awareness, attitude, and acceptance toward cervical cancer prevention among different groups of people in India. We summarized the results of 78 studies to give a comprehensive overview about the level of awareness concerning cervical cancer and its prevention; attitude toward HPV infection, cervical cancer, HPV vaccination and screening; and the acceptance of vaccination, screening, and treatment among different population groups in India.

  Materials and Methods Top

Search strategy

We aimed to identify all papers assessing awareness, attitude, and acceptance with regard to cervical cancer in India between 1980 and 2017, available in PubMed. With the research terms “NOT American Indian” in the strategy and using the following terminology ((((((acceptance) OR attitude) OR perception)OR knowledge) OR awareness) OR acceptability)OR acceptation) AND (cervical cancer OR HPV) AND (India OR Indian Not American Indian) AND (“1980/01/01”[Date-Publication]:”2017/12/31” [Date-Publication]), we identified 270 records. Further, we identified one additional record through Web of Science, Cochrane Library, and IndMED using the same strategy and 10 records using cross-references and Google searches.

Inclusion criteria

The first and second author went through all abstracts and excluded the studies that were not dealing with the awareness and/or attitude and/or acceptance toward cervical cancer prevention. The articles those were dealing with the opinion of decision-makers, politicians, and/or committees; epidemiological studies on risk factors or survival; and studies dealing with the determinants of participation in cervical cancer screening demonstration projects were also excluded from the list. Overall, 77 papers and one dissertation were eligible for analysis and were listed in the order of publication years.[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94] The review process is explained in [Figure 1].
Figure 1: Flow chart showing selection of reviewed records

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Data extraction

Both the first and second authors went through all the articles and prepared a database in excel sheet by extracting the basic information such as first author, publication year, title, study location, study methods, and details of participants [Appendix 1:Description of studies-Extracted information]. Of the 78 studies, only one study was published in 1993,[17] 25 in 2001–2011,[18],[19],[20],[21],[22],[23],[24],[25],[26] but 52 in the last 6 years (2012–2017).[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62],[63],[64],[65],[66],[67],[68],[69],[70],[71],[72],[73],[74],[75],[76],[77],[78],[79],[80],[81],[82],[83],[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94]

The first author extracted information from the selected studies mainly under three headings such as awareness, attitude, and experience, in which awareness was assessed in 60, attitude in 50, and experience in 33 studies with overlapping of these three elements in many of the studies. This was further verified by the second author. The details of studies in separate sections are provided in [Table 1] with proper citations.
Table 1: Summary of studies describing the information on awareness, attitude, and experience

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Description of study methods and participants

There were 64 quantitative studies and eight qualitative studies,[19],[22],[26],[30],[31],[32],[36],[87] whereas six studies used both methods for collecting information.[23],[44],[66],[69],[73],[90] Majority of the studies were cross-sectional surveys using interviews or questionnaires. Few studies were pre- and post-test evaluations,[48],[60],[71],[86] one was a longitudinal study,[35] and the remaining included qualitative interviews, in-depth interviews, and focus group discussions.[19],[22],[23],[26],[30],[31],[32],[36],[44],[66],[69],[73],[87],[90]

Some of the studies had more than one group of participants.[22],[27],[56],[65],[66],[69],[77],[81] The results were compiled and presented according to the above categories of populations.

  Results Top

Many sections included information from both quantitative and qualitative studies, and the extracted information did not have a unique nature to allow easy compilation. [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7] presents the summary of the information extracted from the studies those have some form of uniqueness to summarize. The other information is presented in the text in this section. The awareness regarding other risk factors of cervical cancer [Third column in the awareness section, [Table 1] was excluded from further analysis due to its extreme difficulty in compiling the diverse nature of assessment in different studies.
Table 2: Awareness regarding cervical cancer, its symptoms and etiology

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Table 3: Awareness regarding cervical cancer screening and human papilloma virus vaccination

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Table 4: Readiness to accept human papilloma virus vaccination and screening

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Table 5: Perceptions on barriers and motivating factors to human papilloma virus vaccination

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Table 6: Perceptions on barriers to screening

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Table 7: Screening attendance

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The recognition of cervical cancer as a disease varied according to the population and location of studies. In general nurses and health professionals had a relatively higher level of awareness. The awareness about symptoms as well as HPV infection was also shown a similar pattern [Table 2].

Awareness about the Pap test is very minimal (3.5%–9.7%) among women in the community. Medical students had better knowledge about the Pap tests compared to nonmedical, nursing, and paramedical students, and more than 74% of nurses were aware of the Pap test as a screening tool for cervical cancer. In the community, majority of participants were unaware of the HPV vaccine. Moderate-to-good proportion of nursing or medical students were aware of the vaccine [Table 3], but they had low awareness regarding cost and type of vaccine.[64] Among nurses and health-care providers, the awareness about HPV vaccination varied from 25% to 81% [Table 3].

One qualitative study in Uttar Pradesh reported that even those who heard about or ever had a Pap test or who came for screening were not aware of the purpose of the test, and also the providers had knowledge gaps about the preventive nature of cervical cancer. The same study also reported that many of the providers were aware of the link between HPV and cervical cancer.[22] However, another multicentric study reported that health-care providers in India had a poor understanding of the etiology.[31] In one study conducted in Mysore, parents of adolescents had very poor knowledge about HPV and its relation to cervical cancer.[32] Two studies among migrated Indian women revealed that Indians were less aware about Pap test and its purpose than women from other origins.[26],[34] There was only one study among cervical cancer patients, and it was observed that women ignored the initial symptoms for a long time and did not think that those symptoms would turn as cancer in future.[23] As per the results from a multicentric study, most Indian participants poorly understood about what a vaccine does.[31] None of the parents participated in a study knew about the HPV vaccine,[73] but several parents participated in another study read about the new HPV vaccine.[32]

  Attitude Top

About human papilloma virus infection or cervical cancer

Only 3% of the parents who participated in a study were willing to discuss cervical cancer with their young daughters, and 40% of them preferred to discuss these matters only when their daughters are over 19 years of age, followed by 34% who felt that it is only appropriate to discuss the matter with 15–18 years old girls.[70] Migrated Indian women in Canada often spoke about Pap test and cervical cancer in terms of sexuality and mentioned the inappropriateness of discussing the topic in public.[26] About 30% of women attending gynecology clinics believed cervical cancer is not as serious as other cancers, and 35% of the women perceived themselves to be not at risk. In the same study, one-third of the women believed that the disease can be easily cured and about 75% perceived that effective treatment is available.[29] One study pointed out that many of the women diagnosed with cervical cancer feared disgrace, discrimination, guiltiness, and neglect by their husband and family.[22] In another study, about 63% of the participants (healthy women attending family practice, obstetrics and gynecology clinics, and postnatal wards) revealed that they feel ashamed, embarrassed, guilty, scared, angry, or anxious if they had an HPV infection.[72]

Readiness to accept human papilloma virus vaccination and willingness to screen

The information on vaccine acceptance and willingness to get screen is further summarized and provided in [Table 4]. More than 60% of students in all studies irrespective of medical or nonmedical background had a positive attitude toward the acceptance of HPV vaccination. Although the number of studies on health professionals and young men is very few, the participants of the available studies had a favorable attitude toward HPV vaccination. However, the vaccine acceptability by parents and women from different communities was low.

Even though a small proportion of women attended clinics were willing to be screened (14%–21%), the percentages of women in the community who have had a positive attitude toward screening varied from 33% to 95.5% in general [Table 4]. Female health professionals and nurses also had a favorable attitude toward screening. About 41% of nurses in a study reported that women should get Pap smears done only if they had symptoms [18] and 84% of nurses in another study reported that married women to be screened at least once in a lifetime.[78] The study among migrated Indian women in the UK reported that they do not need smear test if they do not have symptoms (65%), they are not sexually active (39%) and if they are not at risk (22%).[84]

The perceived barriers and motivating factors to HPV vaccination, and perceived barriers for screening were identified from the studies, and a summary is provided in [Table 5] and [Table 6].

Decision-making authority

Three papers had information on who is the final authority to take the decision on vaccinating their daughters. In one study, 61% of Indian women said that the decision whether to accept vaccination for their daughter would be taken by both parents together, 31% said they themselves, and 9% said their husband will take the decision.[33] Others also noted the father's role as crucial in decision-making even though joint parental decision occurs.[31],[32]


With vaccination

Three quantitative studies were found addressing acceptance or experience with HPV vaccination. The first study among pediatricians explored their practices by administering HPV vaccine to young girls.[55] Among the participants, only 3.1% were routinely administering the vaccine, whereas 42.3% selectively and 46% were not at all administering HPV vaccine.[55]

The second study explored the reasons for participation in HPV vaccination among parents or guardians of 9–14-year-old girls.[41] Almost 65% of the respondents gave any of the following three reasons that are: it gives protection against cervical cancer, it prevents disease, or vaccines are good. The most-reported other reasons for participation was “followed others advice.” The major reason for partial or nonparticipation was “absent from school.”[41] As per the third study, 6.8% of the medical or paramedical students were HPV vaccinated.[81]

With screening

The ever participation in screening was ranging from 0% to 53% among different populations in India and from 34% to 87% among migrated Indian women [Table 7].

One study assessed the willingness of Anganwadi (a kind of government-run rural maternal and child health centers) workers to participate in screening before and after the intervention and found that 33% were ready to participate before the intervention, but it became 88% after the intervention.[20] Another study reported that only 10% of the women who already had a Pap smear test came for follow-up visit.[42] In a study on the concerns about self-sampling, about 63% of the participants said that self-sampling is easy, but 64% of women also reported that it hurts oneself.[66]

Cost of services and transportation charges, not aware of the facility, lack of knowledge about screening, believed that test is not necessary, their doctors did not advise them to get Pap smear done, and embarrassment were the most common reasons for nonaccess to the health system or nonparticipation in screening reported by the five studies.[18],[22],[26],[56],[79] Migrated Sikh women also reported that the difference in health system affects their health decisions and screening behaviors.[26]

With diagnosis and treatment

One study in Tamil Nadu among VIA-positive women who refused cryotherapy described the reasons why they did not undergo cryotherapy.[46] Scared of treatment, responsibility to look after their children, no symptoms and hence do not want treatment, and husband did not allow were the most common reasons for refusal to receive cryotherapy.[46] In another study in Uttar Pradesh (including participants from public, private, and military sectors; clients, community members, policy advocates, and providers), worry about self-esteem while undergoing diagnosis and treatment was reported as one of the worst experiences. Lack of confidentiality and privacy to discuss with doctors in front of their son or close relatives were also reported as main barriers while undergoing diagnosis and treatment.[22] A third study was done among cervical cancer survivors in Mumbai. Economic burden, social negligence, fear of remission, and fear of death were the most reported personal and emotional problems they faced during the time of treatment. The positive impact of attending devotional programs, yoga, and meditation practices were also highlighted.[23]

  Discussion Top

The present review suggests that the awareness about cervical cancer, its symptoms, HPV infection, and the preventive nature of the disease were better among medical students and health professionals than among other population groups, where the majority of the people in the community were unaware of all these things. The better awareness of medical students and health professionals is connected with their education and their acquaintance within hospital setup. Hence, the better awareness in such a population is expected. However, the lack of knowledge regarding cervical cancer and its prevention in the general population is well explored in this study and that needs to be addressed properly.

It is observed that women diagnosed with cervical cancer were afraid of disgrace, guiltiness, and neglect by their husband and family.[22] Women also had similar concern if they were diagnosed with HPV infection.[72] Many women perceived themselves to be not at risk [29] and also migrated women felt it inappropriate to discuss cervical cancer in public.[26] These observations reveal that there is a stigma associated with cervical cancer, HPV infection, and sexual behavior. The studies on attitude about HPV vaccination also reveal the same stigma that vaccination would promote sexual promiscuity or premarital sexual intercourse because of the notion of “vaccination for a sexually transmitted infection.”[58] The studies also suggest that even doctors and pediatricians had the stigma on how to introduce this vaccine to their clients.[36] Even though the parents and women from different communities showed a negative attitude, >60% of the students in all reviewed studies had a positive attitude toward acceptance of vaccination, but they were feared of asking the cost of vaccine to their parents because of the above-mentioned reasons.[30] However, the studies suggest that health worker recommendation and having part of the immunization schedule can motivate people to accept HPV vaccination.[18] These results highlight that providing information and motivate medical doctors, especially pediatricians to administer HPV vaccines is crucial to improve acceptance among parents and to increase coverage rates.

The proportion of women who ever participated in screening was moderate to high in migrated Indian women,[21],[28] but in the general population in India, it was very low with a slightly higher proportion among health professionals.[53],[57],[63],[77],[78] It was also observed that an intervention can improve participation,[20] but another study showed that the women coming for follow-up after screening was only 10%.[42] The difference in screening participation between migrated women and the general population of women in India is a reflection of the difference between the two health systems where an organized cervical cancer screening is implemented in one place and such a program is not implemented in another place.

The lack of confidentiality and privacy were reported as major worries of women while attended screening.[22] Furthermore, most often the husband or the head of the family is taking the decision on whether the women have to attend the screening.[33] The personal and emotional problems associated with screening or the treatment of cervical cancer and the fear of social negligence among women is to be addressed and managed appropriately by the health system along with providing knowledge related to vaccination, screening, and the available facilities for screening in their nearby place.

Strength and limitations

The studies included in this review represent different populations from all over India and provides information regarding different groups of people in the population. However, the coverage of studies among migrated Indian women were limited to the hits we identified using our search criteria. We might have missed many studies among migrates Indian women. However, that may not affect the findings of this review since the major purpose was to understand the level of awareness, attitude, and acceptance toward cervical cancer prevention and to explore the challenges of health promotion and education strategies to prevent cervical cancer in India. To the best of our knowledge literature, on such studies are not available.

It was a major challenge to summarize the diverse information from different types of studies. For certain subthemes, the number of studies was very few to make a good summary, and also there were very few studies focusing specific populations, for example, studies done among cervical cancer patients or survivors. Furthermore, the extracted information under the subthemes did not always show a unique pattern, may be due to local or regional differences and differences in study design and methods. Furthermore, many things were unanswered for instance, the attitude of health-care providers and the community toward women attended screening, and/or women diagnosed with HPV infection, cervical precursor, or cancer. Furthermore, the search may not cover all studies conducted in the field, especially the studies published in nonindexed journals. However, to a certain extent, the reviewed studies helped to explore the objectives reasonably.

  Conclusions Top

From a public health perspective, the low level of awareness and negative attitude toward cervical cancer prevention in the population underscores the need for intensive efforts by the public health services in improving awareness and implement interventions aiming at the eventual elimination of this most preventable cancer. Effective cervical cancer prevention in India will substantially contributes to a notable reduction in the global burden of cervical cancer. It is very important to educate the general population about cervical cancer, its risk factors, and preventive measures in such a way that it should reduce the psychosocial barriers and misconceptions about cervical cancer and its prevention. The misconception like screening is not required in the absence of any symptoms and it is required only for women who have many sexual partners, have to be addressed adequately in the community. The role of socioeconomic status in the pathway of cervical cancer progression also should be considered while implementing educational programs. The women should be empowered to find resources and take decisions to access health care for them. If more and more people are aware of cervical cancer, then people would search for preventive measures and facilities for early detection. This will result in increasing demand for preventive measures that in turn will force the public health system to increase and improve the facilities for prevention and early detection. The possibility of potential elimination of cervical cancer is a powerful concept that can drive investments for effective cervical cancer prevention in public health services.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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