Knowledge, attitudes and practices of rural women in South Africa regarding the Pap smear

Abstract

Cancer of the cervix is the second most common form of cancer amongst South African women [1], and the most common cause of cancer mortality among black South African women [2]. The high incidence is complicated by late presentation for treatment as well as misconceptions [3]. The national South African and provincial Eastern Cape policy guidelines on cervical cancer screening encourages all women to have at least three Pap smears in a lifetime. At present, 18 out of the 24 primary health care clinics in the Hewu sub-district of the Eastern Cape have facilities to offer cervical cancer screening, but due to lack of manpower this is not done routinely. The aim of this study was to ascertain the knowledge, practices and attitudes regarding the Pap smear among women in a typical rural setting. The study population included all females aged 18 years and above, who visited the primary health care clinics irrespective of their reasons for the visit. After training by the first author, interviews were conducted in each clinic by the assisting nurse. Interviews were conducted over a period of 9 weeks, following a schedule stipulating the nth woman to be interviewed on which day. Participants gave written informed consent and were interviewed in Xhosa or Sesotho. The protocol was approved by the Ethics Committee, Faculty of Health Sciences, University of the Free State. Of the 620 questionnaires distributed to the clinics, 538 (86.8%) were completed. The median age of the respondents was 40 years (range 18–76 years), and their median educational level grade 7. Approximately two-thirds (63.6%) of the women interviewed had heard about a Pap smear. These women were significantly older (median 42 years vs. 33.5 years, P<0.001), had higher parity (median 3 vs. 2, P<0.001) and higher level of education (median grade 9 vs. grade 8, P<0.001) than those who had not heard of a Pap smear. All further results are provided only for those women who had heard about the Pap smear (n=342). Table 1 shows the distribution of the responses regarding the purpose of the Pap smear. Only 55.6% had ever had one. The main reasons given for not having had a Pap smear was that it was not suggested by the doctor or nurse (40.4%), the woman was not ill so felt it was unnecessary (37.8%) and fear of some sort (32.5%). Cultural and religious beliefs were only indicated by 1.3%. Forty percent of respondents were aware of the government policy guidelines. Of these 60.6% correctly indicated that the policy recommends three free Pap smears in a lifetime. The most frequent response regarding when the first Pap smear should be done was as soon as sexual activity begins (33.0%). Only 1.2% of the respondents indicated that they did not know where a Pap smear could be done. Table 2 shows the responses regarding causes and risk factors that predispose women to cervical cancer. Of the 71% of respondents who said that cancer of the cervix is preventable, 90.7% said it could be prevented by doing a Pap smear. A large proportion of the women knew about a Pap smear, although misconceptions still exist and only half of these women had had a Pap smear. Further education of the population and increased motivation of primary health care nurses to perform cervical screening are high priorities. A dedicated screening team in a mobile clinic or incorporation of screening into routine primary care services should be considered.