Zachowania zdrowotne kobiet w zakresie profilaktyki raka szyjki macicy

Introduction

Cervical cancer is among the most frequent types of cancer concerning the female reproductive organs, and is the second most common cancer in women worldwide. At present, a growing tendency may be noted in morbidity due to cervical cancer. This phenomenon is especially clearly observed in an increasingly younger age group, between 20 and 39 [1, 2]. This is due to inappropriate life style, bad nutritional habits, addictions, contamination of the environment, as well as risky sexual behaviours, including early initiation of sexual activity and a large number of partners. The major cervical cancer risk factor is infection with human papillomavirus (HPV). Approximately 80% of sexually active women experience such an infection in their lives. HPV virus plus additional risk factors, such as cigarette smoking, high parity, and long-term hormonal contraception, cause cervical cancer [3, 4].
Every day, five Polish women die due to cervical cancer. Despite advances in medicine, in Poland, the mortality rates due to this cause still remain high, and in 25% of women this cancer is detected at the stage when it is impossible to cure. In Scandinavian countries, where cervical screening is obligatory for all women, the detection rate is more than 50% [5, 6]. This difference is due to poorly effective prophylaxis [7].
The first symptoms associated with cervical cancer are poorly characteristic and do not evoke concern among women. The first symptoms of dysplasia and cervical cancer may occur as late as 5–10 years after the onset of the cancerous process. The symptoms due to which a woman reports to a physician occur when the cancer is invasive and infiltrates the adjacent tissues. These symptoms include vaginal discharge tinged with blood, with an unpleasant odour, bleeding between periods, contact bleeding (e.g. after intercourse, physical effort, irrigation, hygienic procedures, or palpation examination), lower abdominal pain, and pain in the lumbar spine region. In later periods of the disease, vaginal discharge becomes more abundant with an odoriferous, sweet to nauseous odour caused by necrotic changes and inflammation. Bleeding episodes intensify as a result of tumour lysis, and create a threat to life for the woman. When the cancer is at a very advanced stage, there develop symptoms caused by pressure of the tumour upon adjacent organs, including pain on defecation, difficulties with urination, oedema of the lower extremities and prostration of the body [8, 9].
The treatment of cervical cancer depends on the degree of progression of the tumour. Most often, it is a combined treatment: various methods of treatment are combined, such as surgery, radiotherapy and chemotherapy [10].
Cervical cancer prophylaxis may be divided into the primary prophylaxis, which is related to prevention of occurrence of HPV infections, and secondary prophylaxis, which consists in early detection of symptoms of the disease [11, 12]. For many years, secondary prophylaxis has dominated. At present, this situation may change due to the discovery of a vaccine against oncogenic types of HPV virus. In primary cervical cancer prophylaxis, apart from vaccination against HPV virus, special attention should be paid to the shaping of correct sexual behaviours in order to reduce the spread of HPV virus [13, 14]. Secondary prophylaxis, i.e., early detection, provides the possibility to detect cancer at an early stage at which it may be cured [15, 16]. Prophylactic cervical cancer programmes have been developed, the goal of which is to reduce mortality and morbidity due to cervical cancer, as well as to increase women’s awareness concerning prophylaxis [7, 17]. However, the greatest role in both prevention and early detection of cervical cancer is played by the women themselves, because they decide about their health behaviour.

Aim of the research

The objective of the study was to evaluate health behaviours of women with respect to cervical cancer.

Material and methods

The study covered a group of 15 women aged 20–50, and was conducted during March–April 2015 in the Regional Mother and Newborn Child Centre in Kielce, by the method of a diagnostic survey. The research instrument was a questionnaire designed by the author which consisted of 28 items. The questions were closed, single-choice or multiple-choice. The first four questions concerned the characteristics of the group in the study. The remaining questions pertained to health behaviours presented by the examined women, and their knowledge concerning cervical cancer and its prevention.
The respondents’ knowledge concerning cervical cancer and its prophylaxis was determined based on replies to questions 20–26. For each correct answer to a single-choice question, a score of 1 was ascribed, and for an incorrect answer a score of 0. For multiple-choice questions, several answers could be correct, and scores were ascribed for expressing an opinion about each answer proposed in a question. For example, in a multiple-choice question, where (a) and (b) are correct, a respondent who ticked the answers (a), (d) and (e) obtains a score of 2/5 because he/she:
– ticked answer (a) as correct, and actually this is the correct answer;
– ticked answer (b) as incorrect, whereas this answer is correct;
– ticked answer (c) as incorrect, and actually this answer is incorrect;
– ticked answer (d) as correct, while this answer is incorrect;
– ticked answer (e) as correct, whereas this answer is incorrect.
This respondent ticked correctly 2 out of 5 answers; hence, the score is 2/5. A maximum score of 7 could be obtained (this number of questions were taken into consideration).
Knowledge was evaluated using a school scale:
– 0–3.50 points (0–50% of maximum possible score) – insufficient knowledge;
– 3.51–5.25 points (50–75% of maximum possible score) – satisfactory knowledge;
– 5.26–6.30 points (75–90% of maximum possible score) – good knowledge;
– 6.31–7 points (90–00% of maximum possible score) – very good knowledge.

Statistical analysis

The values of qualitative variables in several groups were compared using the c2 test (with Yates’ correction for 2x2 tables). P-values < 0.05 were considered statistically significant. Statistical calculations were performed using the statistical package R 3.1.2. (R Development Core Team (2009).

Results

The study group comprised 115 women in the Regional Mother and Newborn Child Centre in Kielce, i.e. 100% of the study population. The respondents were aged 20–50. The largest number of them were aged 26–30 – 39 from among 115 women participating in the survey, i.e. 33.91%, whereas the smallest number of respondents were aged 41–45 – 8 women, i.e. 6.96%. The conducted analysis showed that 60 from among 115 women in the study were rural inhabitants (52.17%), and 55 (47.83%) were urban inhabitants. The majority of the examined women had university education – 69 from among 115, i.e. 60.00%. The majority of them were married – 86 from among 115, i.e. 74.78%, followed by 24 who were never married, i.e. 20.87%, and only 1 who was widowed (0.87%).
In the group examined, 33 respondents, i.e. 28.70%, had a cervical test performed within the last year. Women who did not remember the date of the last test constituted 8.70%, while as many as 5.22% of the examined women had never had this test performed (Table 1).
In the examined group, 52 from among 99 respondents who had a cervical test performed and remembered having one performed, i.e. 52.53%, reported for the examination due to complaints, 29, i.e. 29.29%, had a cervical test performed during a visit to a gynaecologist because of pregnancy, and only 9 (9.09%) respondents used the invitation obtained within the cervical screening programme, and also 9 (9.09%) respondents had the cervical test performed when they reported to a gynaecologist on their own initiative for prophylactic purposes (Table 2).
When analysing answers provided by the respondents, 42 from among 99 women in the study who had a cervical test performed and remembered having one performed (42.42%), underwent a cervical test every 2 years, 31 (31.31%) respondents did so every year, whereas 4 (4.04%) respondents had the test every 5 years (Table 3).
Analysis of the results of the survey showed that 20 respondents initiated sexual activity when aged under 18, which constitutes 17.39%. The most frequently indicated age interval was 18–20 (66 women, i.e. 57.39%), followed by 21–25 (26 respondents, i.e. 22.61%) (Figure 1).
The results of the analysis showed that 67 from among 115 (58.26%) respondents had 1 partner or did not have any, followed by 40 (34.78%) respondents who had 2–4 partners, 5 (4.35%) respondents replied that the number of their partners was within the range 5–9, while 3 (2.61%) respondents indicated 10 or more sexual partners (Table 4).
The type of contraception most frequently used by the women in the study is preservative – 64 from among 115 (55.65%) respondents; 38 examined (33.04%) women did not use any contraceptives; while 19 (16.52%) used oral contraceptives (Table 5).
The majority of the women in the study had a satisfactory level of knowledge – 43 from among 115, i.e. 37.39%; followed by unsatisfactory knowledge (21; 18.26%), and very good knowledge (20; 17.39%) (Figure 2).
Among the main causes of cervical cancer, 92 from among 115 women participating in the survey (80.00%) mentioned infection with HPV virus, 73 (63.48%) respondents mentioned a large number of sexual partners, 59 (51.30%) mentioned cigarette smoking, 55 (47.83%) mentioned an early initiation of sexual life, 38 (33.04%) mentioned sexually non-monogamous partners, 31 (26.96%) mentioned age, 20 (17.39%) mentioned a low socioeconomic status, 19 (16.52%) mentioned a large number of childbirths, 5 (4.35%) mentioned high-fat diet, 4 (3.48%) mentioned a small number or lack of childbirths, 2 (1.74%) mentioned a small number of sexual partners, and 1 (0.87%) mentioned late initiation of sexual life (Table 6).
Analysis of the results of the study showed that 86 from among 115 women participating in the study (74.78%) did not know what types of HPV virus are responsible for the development of cervical cancer, while 26 (22.61%) respondents knew that these are types 16 and 18 (Table 7).
The Internet was the most frequently used source of knowledge concerning cervical cancer prophylaxis (71 from among 115 (61.74%) respondents), 56 women in the study (48.70%) acquired their knowledge from a gynaecologist, a nurse was the source of knowledge for 14 women in the survey (12.17%), while the least popular source of knowledge was a female friend – 11 (9.57%) respondents (Figure 3).

Discussion

Cervical cancer is a serious problem in oncologic gynaecology. The main cause of the disease is infection with HPV virus, and other factors increasing the risk of cervical cancer development, including age, early initiation of sexual life, cigarette smoking, a large number of sexual partners and a large number of childbirths. Observance of the principles of cervical cancer prophylaxis allows the reduction in morbidity, or early detection of the cancer creates the chance for total recovery.
The presented study shows that women’s behaviours with respect to cervical cancer prophylaxis are becoming increasingly more positive. While analysing the results of the study, it was discovered that 28.7% of women had had a cervical test performed in the last year. It is a positive fact that 87% of women in the study had a cervical test at least once in 3 years. Efforts should be undertaken to ensure that this percentage continues to increase. Similar results were also obtained by Chosamata M.S. in the study ‘Determinants of cervical cancer screening utilization among women aged 30–45 years in Blantyre District, Malawi’, where the use of cervical screening is also low. The researcher emphasized the necessity for education in order to increase women’s awareness in the area of appropriate use of cervical cancer screening. Apart from regular cervical tests, health behaviours are also of great importance, as well as the elimination of risk factors [18].
The present study shows that women know relatively well the basic cervical cancer risk factors. Among the main causes of cervical cancer, 80.00% of respondents mentioned HPV virus infection, 63.48% mentioned a large number of sexual partners, and 51.30% mentioned cigarette smoking (Table 6). However, detailed information concerning the types of HPV virus associated with cervical cancer were not known to the respondents: 74.78% had no knowledge which types of HPV virus are mainly responsible for the development of this cancer (Table 7).
The respondents’ level of knowledge concerning cervical cancer and its prophylaxis was at a satisfactory level. Nevertheless, women’s behaviours were not equivalent to the knowledge possessed. The most frequent cause of reporting to a gynaecologist was the occurrence of complaints: 52.53% of women in the study, while only 9.09% did so for prophylactic purposes. Despite knowledge of risk factors, 17.39% of respondents initiated sexual life under the age of 18. Similar conclusions were also drawn by other researchers dealing with this scope of problems, and according to the studies by Mastelarz-Migas et al., this was 23.8% of women [19]. Schiffman reported that women who initiated sexual life under the age of 16 are at twice as high risk of contracting cervical cancer than those who initiated sexual life at the age of approximately 20 [20].
The important cervical cancer risk factors are a large number of sexual partners and long-term use of hormonal contraceptives. The study shows that the examined women possessed knowledge concerning this problem, and 58.26% of them had one sexual partner. Hormonal contraceptives were used by 16 (52%) women. It is a positive fact that 55.65% of the women in the study used barrier contraceptive methods – preservatives, which decrease the risk of HPV virus infection.
The Internet constitutes the main source of information concerning cervical cancer for 61.74% of women, for 48.70% it is a gynaecologist, for 33.04% it is magazines, and only for 12.17% of women the major source of information concerning this problem was a nurse. Similar results were obtained by Ulman-Włodarz et al., where for 59% of women the most frequent sources of knowledge of cervical cancer prophylaxis were magazines, television and radio (47%), as well as the Internet (38%). Therefore, it is necessary to increase activities by nurses and midwives in the dissemination of information about cervical cancer and its prophylaxis [16].
The results of the present study showed a relationship between education level and regularity of visits to a gynaecologist (the higher the education level, the higher the regularity of visits) and between education and prophylactic action undertaken and cigarette smoking (Tables 8–12). Lipska et al., in their studies, found a relationship between health-promoting behaviours of women and their age and state of knowledge. Women at an older age showed more incorrect behaviours, compared to those who were younger. It was also found that place of residence had no effect on health behaviours of women [13].
Studies by Bakalczuk et al. demonstrated that in the last year, 23% of women had a cervical test performed, within the last 2 years 30% of respondents had one, while 20% of them had never had this test performed. Our study presents a more positive image of the situation, where 28.70% had a cervical test performed within the last year, 20.00% had one within the last 3 years, 19.13% had one within the last 2 years, 18.26% had one more than 4 years ago, 8.70% did not remember when they had the test performed, whereas 5.22% had never had the test [14]. Studies by many researchers demonstrate that activities undertaken in the area of prevention and early detection of cervical cancer in Poland are still insufficient. The main problem in Polish society is a change of women’s attitude towards protection and responsibility for their own health [21].

Conclusions

Health behaviours of women with respect to cervical cancer prophylaxis are becoming increasingly more positive, which is the result of widely conducted education. However, the occurring complaints, and not prophylactic purposes, still remain the major cause of women’s visits to a gynaecologist. Actions should be undertaken to encourage women to participate in the Population Programme of Cervical Cancer Prophylaxis and Early Detection.
Women’s level of knowledge concerning cervical cancer and its prophylaxis remains at a satisfactory level. The women possess knowledge of the main risk factors. It is necessary to intensify educational actions providing detailed information pertaining to cervical cancer, undertaking risky sexual behaviours, and benefits resulting from vaccination against the HPV virus.
No statistically significant differences were observed between health behaviours of women in the area of cervical cancer prophylaxis and their place of residence and marital status. A statistical relationship was found between women’s age and frequency of cigarette smoking, education level and regularity of visits to a gynaecologist: the higher the education level, the higher the regularity of visits. Education had an effect on undertaking prophylactic actions and the frequency of smoking: the higher the education level, the higher the frequency of undertaking prophylactic actions, and the lower the frequency of smoking.
In the population examined, the Internet constituted the major source of information concerning cervical cancer and its prophylaxis. However, the Internet provides knowledge which is not thorough and is sometimes unreliable. Greater activity of nurses and midwives is recommended in the imparting of professional and reliable information about the problem of cervical cancer and its prophylaxis.

Conflict of interest

The authors declare no conflict of interest.

References

1. Didkowska J, Wojciechowska U. Zachorowania i zgony na nowotwory złośliwe w Polsce. Krajowy Rejestr Nowotworów. Centrum Onkologii – Instytut im. Marii Skłodowskiej /http://onkologia.org.pl/k/epidemiologia/-27.01.2015.
2. Łoś J. Skryning cytologiczny raka szyjki macicy. Ginekol Prakt 2006; 88: 10-43.
3. Krasnodębski J, Dawid P, Chudyba R. Współczesne sposoby profilaktyki raka szyjki macicy. Ginekol Prakt 2007; 2: 11-4.
4. Michalska M. Epidemiologia raka szyjki macicy. In: Rak szyjki macicy. Profilaktyka, diagnostyka i leczenie. Spaczyński M, Kędzia W, Nowak-Markwitz E (eds.). Wydawnictwo Lekarskie PZWL, Warsaw 2009; 1-13.
5. Nowicki A, Borowa I, Maruszak M. Zachowania zdrowotne kobiet w zakresie zapobiegania, wczesnego wykrywania stanów przedrakowych i raka szyjki macicy. Ginekol Pol 2008; 79: 840-9.
6. Spaczyński M, Nowak-Markwitz E, Januszek-Michalecka L, Karowicz-Blińska A. Women’s social conditions and their participation in Cervical Cancer Population Screening Programme Poland. Ginekol Pol 2009; 80: 833-8.
7. Smoleń E, Dobrowolska B, Pilewska-Kozak AB. Women’s knowledge about cervical carcinoma risk factors and their health behaviours: study among nurses. Prog Health Sci 2015; 5: 87-92.
8. Wrześniewska M, Adamczyk-Gruszka O, Gruszka J, Bąk B. Możliwości diagnostyczne i diagnostyczno-terapeutyczne w profilaktyce raka szyjki macicy. Studia Medyczne 2013; 29: 109-16.
9. Pacewicz M, Krajewska-Kułak E, Krajewska-Fernishah K. Profilaktyka raka szyjki macicy – poziom wiedzy kobiet i mężczyzn. Med Paliat 2012; 4: 217-28.
10. Markowska J, Bidziński M, Markowska A. Rak gruczołowy szyjki macicy w świetle profilaktyki. Ginekol Onkol 2009; 7: 83-7.
11. Czechowska K. Wiedza i zachowania prozdrowotne kobiet w zakresie profilaktyki raka szyjki macicy na podstawie badań pacjentek z powiatu jeleniogórskiego. Acta Scholae Superioris Medicinae Legnicensis 2008; 1: 7-12.
12. Mazur A. Opieka w terapii nowotworów ginekologicznych. In: Pielęgniarstwo onkologiczne. Koper A (ed.). Wydawnictwo Lekarskie PZWL, Warsaw 2011; 209-15.
13. Lipska A, Karnia A, Włoch A, Lipska-Stańczak M, Opuchlik A. Poziom wiedzy o czynnikach ryzyka wystąpienia raka szyjki macicy a zachowaniami prozdrowotnymi kobiet z terenu województwa świętokrzyskiego. Studia Medyczne 2014; 30: 196-202.
14. Bulsa M, Czaja-Bulsa G. Profilaktyka pierwotna i wtórna raka szyjki macicy. Fam Med Primary Care Rev 2006; 8: 373-4.
15. Bakalczuk G, Wdowiak A, Lewicka M, Bąk M, Bakalczuk S,Kanadys K. Ocena wykonywania profilaktycznych badań cytologicznych przez kobiety w okresie okołomenopauzalnym. Prz Menopauz 2012; 11: 129-34.
16. Ulman-Włodarz I, Nowosielski K, Romanik M, Pozowski J,Jurek M. Świadomość profilaktyki raka szyjki macicy wśród kobiet zgłaszających się do poradni K. Ginekol Pol 2011; 82: 22-5.
17. Wójcik-Krowiranda K, Michalski T, Bienkiewicz A. Stany przednowotworowe w ginekologii. Post Nauk Med 2013; 7: 466-74.
18. Chosamata MS, Hong SA, Tiraphat S. Determinants of cervical cancer screening utilization among women aged 30-45 years in Blantyre District, Malawi. J Pub Health Dev 2015; 13: 3-18.
19. Mastelarz-Migas A, Nowak A, Steciwko A. Wiedza i świadomość młodych kobiet w zakresie profilaktyki raka szyjki macicy. Fam Med Primary Care Rev 2011; 13: 443-5.
20. Schiffman MH, Bauer HM, Hoover RN, Glass AG, Cadell DM, Rush BB, Scott DR, Sherman ME, Kurman RJ, Wacholder S, et al. Epidemiologic evidence showing that human papilloma virus infection causes most cervical intraepithelial neoplasia. J Natl Cancer Inst 1993; 85: 958-64.
21. Komunikat CBOS, BS/57/2002. Kobiety o profilaktyce raka piersi i raka szyjki macicy. Warszawa 2012; 1-11.

Address for correspondence:

Martyna Wychowaniec MD
Faculty of Medicine and Health Science
Jan Kochanowski University
al. IX Wieków Kielc 19, 25-317 Kielce, Poland
Phone: +48 693 716 969
E-mail: martynawychowaniec@o2.pl