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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 27  |  Issue : 4  |  Page : 343-347

Effectiveness of audio-visual and print media intervention on knowledge of cervical health among rural women in Southern India


1 Department of Biochemistry, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal, Karnataka, India
2 Department of Global Health, Prasanna School of Public Health, MSW Program, Manipal Academy of Higher Education, Manipal, Karnataka, India
3 Department of Anatomy, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
4 Department of Community Medicine, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal, Karnataka, India

Date of Submission15-May-2020
Date of Decision18-May-2020
Date of Acceptance13-Jul-2020
Date of Web Publication04-Nov-2020

Correspondence Address:
Dr. Varalakshmi Chandrasekaran
Department of Community Medicine, Melaka Manipal Medical College (Manipal Campus), Manipal Academy of Higher Education, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/npmj.npmj_148_20

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  Abstract 


Background: Cervical cancer health education programmes are not accessible to rural women in developing countries. Objective: Our study aimed at assessing the health literacy about cervical cancer amongst the rural women in Udupi district, southern India, before and following intervention using audio-visual aid/face-to-face interactive sessions versus pamphlets alone. Methods: This was a quasi-experimental study. A total of 166 women participated in the study. Participant groups were allocated into two interventional (Experimental/Control) groups. Participants in the experimental group received education through the video followed by face-to-face interaction with a health educator while those in the control group received a pamphlet. A validated questionnaire was used to assess knowledge about numerous risk factors, Pap smear test and treatment of cervical cancer (pre- and post-intervention test). The findings are presented as frequencies and percentages. Paired responses were compared for individual questions using McNemar test and P < 0.05 was fixed as statistically significant. Results: Former to the intervention, 13.5% and 19.1% in the experimental and control groups, respectively, felt that personal hygiene was important to prevent cervical cancer. Both the groups had very limited knowledge regarding risk factors (93.6%; 94%), symptoms (96.3%; 97.6%) and knowledge that Pap smears can reduce the risk of cervical cancer (91.7%; 93.9%). The change in knowledge pre-and post-intervention in both groups increased significantly. Conclusion: Intervention with face-to-face interactive sessions showed a positive impact on knowledge regarding cervical cancer. These findings indicate both methods can be effective in providing health education in the community.

Keywords: Audio-visual, cervical cancer, rural women, human papillomavirus, Pap smear


How to cite this article:
Nagamma T, Ashok L, Konuri A, Chandrasekaran V. Effectiveness of audio-visual and print media intervention on knowledge of cervical health among rural women in Southern India. Niger Postgrad Med J 2020;27:343-7

How to cite this URL:
Nagamma T, Ashok L, Konuri A, Chandrasekaran V. Effectiveness of audio-visual and print media intervention on knowledge of cervical health among rural women in Southern India. Niger Postgrad Med J [serial online] 2020 [cited 2020 Nov 24];27:343-7. Available from: https://www.npmj.org/text.asp?2020/27/4/343/299902




  Introduction Top


According to the WHO, every year 300,000 women die due to cervical cancer, while 85% of these deaths are mainly from undeveloped regions of the world.[1] Sexually transmitted human papillomavirus (HPV) mainly causes cervical cancer.[2] The progression of cancer takes 10–20 years from mild dysplasia to carcinoma cervix in women with normal immune response.[3] Cervical HPV infection results in morphological lesions ranging from normal cytology to precancerous lesions and invasive cervical cancer.[4] The other risk factors associated with HPV infection are poor hygiene practices, multiple sex partners, marriage at an early age, multiple pregnancies, chlamydia trachomatis co-infection and immunosuppression.[5] Mortality resulting from cervical cancer is preventable if detected at its early stages and screening with the Pap smear test. The cancer occurrence is alarming in rural populations where the majority of women are unaware of risk factors and the effectiveness of screening programs due to their illiteracy. They are socio-economically weak and have poor hygienic practices and other risk factors such as marriage at young age and numerous pregnancies. Besides, medical services, guidance and awareness programmes are virtually non-existant.[6] Regular cervical cytological examinations, genital hygiene and detection at an early age can control carcinoma of the cervix.

Most rural women in the Indian context also belong to a low socioeconomic background, poor sanitary circumstances and have many other risk factors that contribute to cervical cancer. Cervical cancer health education programmes are not accessible to rural women in developing countries to educate women, their families and the community. One should understand that cervical cancer is preventable by detection in the early stage.[7] Since the morbidity and mortality due to cervical cancer are high in the Indian context, this study aimed at exploring the effectiveness of two interventions on cervical health literacy amongst rural women. In the present study, educational interventions on cervical health and cancer were tested to identify which of the modalities was effective in creating awareness of the disease. Specifically, the study tested the outcomes following two modes of intervention on cervical health literacy amongst rural women.


  Methods Top


Study design

The study employed a quasi-experimental approach using pre-test-post-test design in both the experimental and control groups. The study was conducted over 1 year between September 2015 and September 2016. The sample size was estimated based on a previous study.[8]



Where: P1= 0.74 (knowledge of cervical cancer from previous study); P2= 0.94 (expecting a 20% increase in knowledge); P1P2= 0.20; P = P1+ P2/2 = 0.84; n = 53.71. Assuming a non-response rate (NR) of 30%: n1 = n/(1-NR); n1 = 76.7 participants required per group.

Study participants

The number of women in the experimental group consisted of 82 participants, while the control group consisted of 84 participants. Seven sessions of intervention were conducted overall with a total of 166 participants. The experimental group received the audio-visual intervention while the control group received pamphlets. The women were drawn from three taluks that fell under the jurisdiction of the Udupi district, including Udupi, Karkala, and Kundapura taluks. The women were invited to participate during their regular visit at an Anganwadi training centre. In all, 166 women participated, with 91 from Udupi taluk, 35 from Karkala taluk and 40 from Kundapura taluk.

Ethical considerations

Ethical clearance was obtained from the Institutional Ethical Committee at a tertiary care hospital in Manipal (IEC 438/2015). Written approval was obtained from all the women who voluntarily took part in the study.

Sampling method

The participants were assigned to the two intervention groups. This was a quasi-experimental study. The women were identified consecutively at the community level through Anganwadis. When they visited the Anganwadi training centres in groups of 20–30, each group was alternately included in the experimental and control groups. Two types of interventions were used, including a pamphlet containing information on cervical cancer to the control group and the second intervention was provided for the experimental group using audio-visual aid as well as a teaching and interactive session for about 30 min. This was provided in Kannada, the local language. Contamination between groups was reduced as all members of each group were allotted either to the experimental or control group.

Data collection

A questionnaire was designed and validated to assess their cervical health literacy including knowledge on various risk factors and treatment of cervical cancer. The questionnaire was developed following a literature review and then validated by an oncologist, gynaecologist and public health professional. The questionnaire was translated into the local language (Kannada) by language experts. The questionnaires were self-administered as the participants were educated as included in [Table 1].
Table 1: Demographic characteristics of participants

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Study procedure

Overall, the participants were met over seven sessions. In each of the sessions, 18–25 participants took part. Participants were provided with a pre-test pro forma consisting of questions related to socio-demographic details and included questions related to cervical health literacy that tested for knowledge and practices about cervical cancer. Each alternate group was assigned to either the experimental or control group. Immediate post-test following the intervention was then conducted for both the groups using a self-administered questionnaire to assess for change in knowledge.

Data analysis

SPSS version 20 (SPSS south Asia, Bangalore) was used to analyse the data. Frequencies and percentages were reported for descriptive data, while the McNemar test was used to assess for significant change within groups with a P < 0.05 being considered as statistically significant.


  Results Top


A sum of 166 participants were recruited. The age of the study population ranges from 18 to 55 years (42.5 ± 2.5). The majority (84.9%) of the women were married and most of them married between the ages of 18–30 years. A small proportion (5.4%) of the study population had three to four children. Most (89.6%) of the study population had breastfed the child. The literacy rate in women was 100%, out of which 38% had primary education, 43.4% had secondary level of education and 18.6% of the women completed their graduation [Table 1]. The common sources of information on cervical cancer mentioned by participants were mass media (56.7%) followed by the magazine (34.7%) and through campaigns (8.6%).

[Table 2] shows the knowledge in the pre- and post-audio-visual and health education intervention. Prior to the intervention with the audio-visual aid and face-to-face interactive sessions, 13.5% felt that personal hygiene was important to prevent cervical cancer after the post-test; the knowledge had improved to 89%. Before the intervention, 6.4% knew regarding at least two risk factors, 3.7% were aware of the symptoms, 30.4% knew regarding the use of Pap smear test to detect cervical cancer, 15.8% felt that the use of condoms reduced the risk, 3.7% sensed that limiting the number of sexual partners helps to prevent cancer and 25.6% opined that early detection and treatment leads to better outcomes. Following the audio-visual/face-to-face interactive sessions in the experimental group, the knowledge improvement across several variables was statistically significant (P < 0.001).
Table 2: Assessment of knowledge of cervical cancer pre- and post-audio-visual and health education intervention

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Among the control group on the pre-test, only 19.1% of the women had good knowledge about personal hygiene practices as important in preventing cervical cancer. Following administration of the pamphlet, their knowledge significantly improved (64.2%; P = 0.001). The participants had low knowledge regarding the causes of cervical cancer (2.4%), Pap smear to detect cancer (21.4%), the virus causing the disease (4.8%) and symptoms (2.4%). The knowledge improved significantly post-test (P = 0.001) [Table 3].
Table 3: Assessment of knowledge of cervical cancer pre- and post-administration of pamphlets

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  Discussion Top


The current study analysed the effect of two different interventional materials amongst rural women. Although we observed that knowledge on personal hygiene practices, risk factors and symptoms, as well as prevention and treatment of cervical cancer was present in both groups, it was observed that the knowledge post the intervention, improved in both groups. The previous research on knowledge and attitude amongst rural women regarding cervical carcinoma has reported the need for health education programs in creating awareness among women in the community.[9] In both the groups after the post, interventional participants were able to identify more than two symptoms, including pain during vaginal intercourse, vaginal bleeding and bleeding after menopause. The knowledge in both groups regarding pap smear test, HPV as a cause for cervical cancer and treatability if diagnosed in the early stage was significantly increased (P = 0.001) post-intervention test. A study conducted by Shobeiri et al., small group intervention for 45–60 min' consultation, each session included a combination of PowerPoint display, group discussions, questions and answers. The pamphlets were given to the participants after the session. The control group did not receive any health education. After the intervention, there was a significant increase (P < 0.001) in the mean score of knowledge in the intervention group.[10]

In another quasi-experimental study in Iran, an intervention involving a health education session on cervical cancer for 1.5 h was held through films, lectures and discussion. They observed that there was a significant change before and following the intervention.[11] In our study, before the intervention, the majority of participants in both groups were unable to identify the role of personal hygiene practices in preventing cervical cancer, and the risk factors and symptoms of cervical cancer. Our results are consistent with another study, which revealed that both the interventional group participants did not have good knowledge about the signs and symptoms of cancer before the intervention.[12] The major risk factors associated with cervical cancer were identified as being infected with HPV and other risk factors such as multiple sexual partners, marriage at an early age, several pregnancies and lack of genital hygiene in women.[5],[13] Knowledge regarding Pap smear test and HPV is also low in both groups before intervention. In the experimental group (93.9%) and control group (91.7%), participants did not know that regular Pap smear reduces the risk of cervical cancer. However, after the intervention in both the groups, the knowledge improved significantly (P = 0.001).

Studies have reported that despite significant awareness of a link between cervical cancer and sexual activity, none of the respondents had heard of HPV, but after providing the health education, their knowledge had improved about HPV and protection against cervical cancer using a vaccine.[14] The Pap smear and screening test were neglected due to lack of education, awareness and poor knowledge on cervical cancer in women. A study conducted in rural area Tamil Nadu, India, observed that there was low acceptance of screening tests in spite of access to cervical screening programs. Later, the number of women undergoing screening increased by the optimisation of health information and attitudes of the people.[15] One of the observations in our study was that the participants' knowledge related to Pap smear in identifying cervical cancer improved significantly in both groups post-intervention.

Limitations

The limitations in our study include that the questionnaire was self-administered and hence, there may be some response bias on the part of the participants. In addition, a few of the participants were hesitant to fill the questionnaires as they did not know the answers following informed consent as several of them stated that they had never heard of cervical cancer or its prevention prior. They were encouraged to answer to the best of their knowledge.


  Conclusion Top


This interventional study assessed the effect of educational interventions using a combination of audio-visual aid and face-to-face interactive sessions versus only a pamphlet on the health literacy related to cervical cancer amongst rural women in the Indian context. The knowledge related to cervical cancer prior to the intervention was quite low, however, post-intervention, there was a statistically significant increase in the knowledge of the participants. Our findings are substantiated by literature in other settings.[16] The present study highlights the need for disseminating health information in the community and the importance of improving knowledge related to cervical cancer. In the absence of electronic aids, the use of pamphlets has also been demonstrated. These methods if feasible at the grass-root level may have an impact on improving the health literacy concerning cervical cancer among populations that are in urgent need of such information.

Acknowledgement

We would like to thank Dr. Ciraj, Director, MAHE-FAIMER International Institute for Leadership in Inter Professional Education, Manipal Academy of Higher Education, Manipal, India. Mr. Ishwar and Ms. Nishmit Vas S, Anganwadi Training Center, Manipal Academy of Higher Education, Manipal, for their constant support during the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organization. New Toolkit to Improve Collection and Use of Data in Cervical Cancer Programmes. Geneva: World Health Organization; 2019. Available from: https://www.who.int/ncds/surveillance/new-toolkit-improve-collection-use-data-cervical-canceren/. [Last accessed on 2019 Jul 29].  Back to cited text no. 1
    
2.
World Health Organization. Human Papillomavirus (HPV) and Cervical Cancer. Geneva: World Health Organization; 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/human-papillomavirus-(hpv)-and-cervical-cancer. [Last accessed on 2020 Jun 19].  Back to cited text no. 2
    
3.
World Health Organization. Comprehensive Cervical Cancer Control: A guide to Essential Practice. Geneva: World Health Organization; 2006. Available from: https://www.who.int/reproductivehealth/publications/cancers/cervical-cancer-guide/en/. [Last accessed on 2019 Jul 29].  Back to cited text no. 3
    
4.
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, et al. Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer; 2018. Available from: https://gco.iarc.fr/today. [Last accessed on 2019 Jul 29].  Back to cited text no. 4
    
5.
Hussain S, Bharadwaj M, Nasare V, Kumari M, Sharma S, Hedau S, et al. Human papillomavirus infection among young adolescents in India: Impact of vaccination. J Med Virol 2012;84:298-305.  Back to cited text no. 5
    
6.
Badwe RA, Dikshit R, Laversanne M, Bray F. Cancer incidence trends in India. Jpn J Clin Oncol 2014;44:401-7.  Back to cited text no. 6
    
7.
Jayant K, Nene BM, Badwe RA, Panse NS, Thorat RV, Khan FY. Rural cancer registry at Barshi, Maharashtra and its impact on cancer control. Natl Med J India 2010;23:274-7.  Back to cited text no. 7
    
8.
Singh E, Seth S, Rani V, Srivastava DK. Awareness of cervical cancer screening among nursing staff in a tertiary institution of rural India. J Gynecol Oncol 2012;23:141-6.  Back to cited text no. 8
    
9.
Siddharthar J, Rajkumar B, Deivasigamani K. Knowledge, awareness and prevention of cervical cancer among women attending a tertiary care hospital in Puducherry, India. J Clin Diagn Res 2014;8:OC01-3.  Back to cited text no. 9
    
10.
Shobeiri F, Javad MT, Parsa P, Roshanaei G. Effects of group training based on the health belief model on knowledge and behavior regarding the pap smear test in Iranian women: A quasi-experimental study. Asian Pac J Cancer Prev 2016;17:2871-6.  Back to cited text no. 10
    
11.
Daryani S, Shojaeezadeh D, Batebi A, Charati JY, Naghibi A. The effect of education based on a health belief model in women's practice with regard to the Pap smear test. J Cancer Policy 2016;8:51-6.  Back to cited text no. 11
    
12.
Issah F, Maree JE, Mwinituo PP. Expressions of cervical cancer-related signs and symptoms. Eur J Oncol Nurs 2011;15:67-72.  Back to cited text no. 12
    
13.
Nagamma T, Seng VL, Leng CC, Alias NA, Karim NA. Assessment of knowledge, awareness and preventive measures of cervical cancer among female medical students. BJMS 2016;4:583-7.  Back to cited text no. 13
    
14.
Wong LP, Wong YL, Low WY, Khoo EM, Shuib R. Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Pap smear: A qualitative study. Singapore Med J 2009;50:49-53.  Back to cited text no. 14
    
15.
Isaac R, Finkel M, Olver I, Annie IK, Prashanth HR, Subhashini J, et al. Translating evidence into practice in low resource settings: Cervical cancer screening tests are only part of the solution in rural India. Asian Pac J Cancer Prev 2012;13:4169-72.  Back to cited text no. 15
    
16.
Abiodun OA, Olu-Abiodun OO, Sotunsa JO, Oluwole FA. Impact of health education intervention on knowledge and perception of cervical cancer and cervical screening uptake among adult women in rural communities in Nigeria. BMC Public Health 2014;14:814.  Back to cited text no. 16
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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