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Gynecologic Oncology 9

Original Research Report

Awareness of cervical cancer screening among women in Serbia

Vesna Kesica,*, Milica Markovicb, Bojana Matejicc, Lidija Topicd

aInstitute of Obstetrics and Gynecology, Clinical Center of Serbia, The University of Belgrade, Visegradska 26, 11000 Beograd, Serbia and MontenegrobDepartment of Public Health, The University of Melbourne, Australia

cInstitute of Social Medicine, Medical School, The University of Belgrade, Serbia and MontenegrodInstitute of Social Sciences, The University of Belgrade, Serbia and Montenegro

Available online 19 September 2005

Abstract

Background. The success of cervical cancer screening programs in North America and Western Europe has led to their expansion into

other regions of the world. As these services become available on a large scale in other countries, it is imperative to understand the

background conditions that may present challenges to their effectiveness there.

Methods. Women were recruited from two different areas in Central Serbia. Both focus group discussions and survey instruments were

used to gauge participants’ knowledge and attitudes about cervical cancer screening issues.

Results. Results were mostly similar to comparable studies performed in other regions. Education and economic status were not highly

related to knowledge about cervical screening. The population sampled showed a broad lack of knowledge about the necessity of screening

and shared attitudinal barriers with women in other regions.

Conclusion. The success of public awareness campaigns elsewhere suggests that a media-centered approach could have good results in

Serbia. The lack of media attention noted in the study focus groups supports this conclusion.

D 2005 Elsevier Inc. All rights reserved.

Keywords: Cancer prevention; Health education; Health practices; Health beliefs; Qualitative research; Quantitative research

Introduction

Cervical cancer screening has been shown to signifi-

cantly reduce both incidence and mortality rates wherever a

comprehensive program has been established. But varying

conditions in different regions of the world give rise to

different results and new challenges. In the context of

cervical cancer screening in Serbia, high incidence and

mortality rates in are not surprising. International research

has indicated that cervical cancer screening behavior is

determined by women’s knowledge and attitudes about

cervical cancer as well as access to health services. Given

the paucity of research on cervical cancer screening in

countries which do not offer universal screening [5,7], a

study was undertaken to investigate what women in Central

Serbia know about cervical cancer and the factors that

impact their screening behavior. Cervical cancer screening

0090-8258/$ - see front matter D 2005 Elsevier Inc. All rights reserved.

doi:10.1016/j.ygyno.2005.07.092

* Corresponding author.

E-mail address: vek@EUnet.yu (V. Kesic).

in Serbia is performed by gynecologists only, in contrast to

the international practice (e.g., Denmark, Australia) where

general practitioners may have this role.

Methodology

This study was conducted between May 2003 and

October 2004 in the capital, Belgrade, and a regional town,

Smederevo, to elicit information from women residing in

different social and geographical contexts. The study

included qualitative (phase I—focus group discussions and

in-depth interviews with women) and quantitative (phase

II—community-based survey) research. The women were

recruited by the network sampling (qualitative component)

and random stratified sampling (quantitative component)

techniques. In total, nine focus groups were conducted and

62 women participated in them. Each focus group was

composed of women with different educational background

but with similar age. In-depth interviews were conducted

9 (2005) S222 – S225

YGYNO-971141; No. of pages: 5; 4C: 4, 5

Table 1

Women’s presentation to a gynecologist in relation to education

Last visit to gynecologist Education, number (%) of participants Total

Primary or less Trade High school University

In this year 88 (28.8) 18 (30.0) 122 (36.3) 31 (42.6) 259 (33.4)

In the last 2 years 79 (25.8) 10 (16.7) 69 (20.5) 11 (15.1) 169 (21.8)

3 years ago 76 (24.8) 13 (21.7) 43 (12.8) 11 (15.1) 143 (18.5)

Between 3 and 5 years ago 33 (10.8) 8 (13.3) 31 (9.2) 8 (10.9) 80 (10.3)

More than 5 years ago 22 (7.2) 4 (6.6) 22 (6.6) 3 (4.1) 51 (6.6)

Never 8 (2.6) 7 (11.7) 49 (14.6) 9 (12.32) 73 (9.4)

Total 306 60 336 73 775

m2 = 7.144; df = 15; P = 0.128.

V. Kesic et al. / Gynecologic Oncology 99 (2005) S222–S225 S223

with 22 women (18 with healthy women, 3 with women

with a history of cervical abnormality and 1 with a woman

who has had cervical cancer). Thematic analysis of

Table 2

Women’s knowledge and practices in relation to cervical cancer, survey

data

No. (%) of participants

Belgrade,

n = 489

Smederevo,

n = 286

Total,

n = 775

I believe that women must have symptoms if they have cervical cancer

I agree 239 (48.9) 151 (52.8) 390 (50.3)

I do not agree 117 (23.9) 67 (23.4) 184 (23.7)

Not sure 113 (27.2) 68 (23.8) 201 (25.9)

I am insufficiently informed about cervical cancer

I agree 333 (61.8) 192 (67.1) 525 (67.7)

I do not agree 79 (16.2) 49 (17.1) 128 (16.5)

Not sure 76 (15.5) 45 (15.8) 121 (15.6)

Last visit to the gynecologist

In this year 186 (38) 73 (25.5) 259 (33.4)

1–2 years ago 105 (21.5) 64 (22.4) 169 (21.8)

More than 5 years ago 103 (21.1) 40 (14) 143 (18.5)

5–10 years ago 44 (9) 36 (12.6) 80 (10.3)

More than 10 years ago 33 (6.7) 18 (6.3) 51 (6.6)

Never 18 (3.7) 55 (19.2) 73 (9.4)

Have you ever had

Pap test 404 (82.6) 107 (37.4) 511 (65.9)

Colposcopy 228 (46.6) 102 (35.7) 330 (42.6)

Biopsy 44 (9) 22 (7.7) 66 (8.5)

Gynecologic surgery 22 (4.5) 37 (12.9) 59 (7.6)

Last time a gynecologist performed any of the examinations

In this year 168 (34.4) 46 (16.1) 214 (27.8)

In the last 2 years 101 (20.7) 19 (6.6) 120 (15.6)

3 years ago 52 (10.6) 22 (7.7) 74 (9.6)

Between 3 and 5 years ago 41 (8.4) 17 (5.9) 58 (7.5)

More than 5 years ago 57 (11.7) 35 (12.4) 92 (11.9)

Never 68 (13.9) 147 (51.3) 212 (27.5)

Reasons for irregular check-ups

Crowded out-patient departments 67 (13.7) 26 (9.1) 93 (12)

I am too busy 57 (11) 24 (8.4) 78 (10)

I cannot afford a

private gynecologist

14 (2.9) 7 (2.4) 21 (2.7)

I do not have any health problems 28 (5.7) 18 (6.3) 46 (5.9)

I have had a bad

experience with a gynecologist

8 (1.6) 4 (1.4) 12 (1.5)

I am embarrassed 29 (5.9) 23 (8) 52 (6.7)

I am afraid 48 (9.8) 25 (8.7) 73 (9.4)

I am lazy 72 (14.7) 39 (13.6) 11 (14.3)

I am healthy, there is no need 98 (20) 61 (21.3) 159 (20.5)

That is doctor’s recommendation 7 (1.4) 0 (0) 7 (0.9)

Nothing in particular 36 (7.4) 71 (24.6) 113 (13.8)

qualitative data was conducted by employing ATLAS-ti

software and informed the survey questionnaire on women’s

lay understanding and knowledge of cervical cancer and

screening. A cross-sectional survey was conducted with

women aged 18–70, assessing community health centers.

The sample mainly consisted of middle-aged women (age

35–55, 60.6%), mostly married (68.9%) with children

(81.2%). A majority had only primary high school education

(90.6%) and average or poor self-reported financial status

(98.1%). The response rate was 96.8% and 776 participated

in the survey. The data collection instrument was a

semistructured questionnaire designed to collect self-

reported data on women’s knowledge, attitudes and practi-

ces in relation to reproductive health. A particular focus was

placed on cervical cancer and screening. The SPSS software

was used for quantitative data entry and analysis. In this

paper, we present the quantitative results.

Results and discussion

This study revealed that approximately half of women

regularly visit a gynecologist (Table 1). Residential setting

influenced presentation to a gynecologist: Women from

Smederevo were less likely to have visited a gynecologist

recently than those from Belgrade. Education and financial

status had small impact on women’s presentation for

screening. A variety of social factors predicted poor

Table 3

Women’s knowledge of who should receive cervical cancer screening

No. (%) of

participants

Older women 415 (53.5)

Women with family history of

malignant diseases

307 (39.6)

Women who frequently change

sexual partners

218 (28.1)

Middle-aged women 152 (19.6)

Women who smoke

cigarettes or ex-smokers

129 (16.6)

Women who have had at least

one sexual intercourse

60 (7.7)

Young women 46 (5.9)

I do not know 46 (5.9)

Table 4

Media and information on cervical cancer

No. (%) of

participants

Did not have an opportunity to read

or hear anything about cervical cancer

109 (14.6)

Very interested about all health topics,

as well as cervical cancer

130 (16.8)

Occasionally hear something about the topic 386 (49.8)

Not interested but aware of importance 124 (16)

It is not important to be informed about the topic 25 (3.2)

V. Kesic et al. / Gynecologic Oncology 99 (2005) S222–S225S224

screening behavior (Table 2), with most women arguing that

they were healthy (20.5%), followed by women being lazy

(14.3%) or afraid (9.4%) to see a gynecologist. Some

women (13.9%) did not state a particular reason for not

going to a gynecologist. Women’s knowledge of who

should receive cervical cancer screening was poor (Table

3). They mainly thought that older women should receive

cervical cancer screening (53.5%). Only a minority of

women stated that young women or those who were

sexually active (5.9% and 7.7%, respectively) should

present for a screening. A significant proportion of women

believed that they were insufficiently informed about

cervical cancer (67.8%). Only 18.2% received information

on cervical cancer and screening from a gynecologist. The

media were also a poor source of comprehensive informa-

tion on cervical cancer (Table 4).

The findings of this research are not dissimilar to other

studies regarding factors impacting access to cervical cancer

screening [1–6], with the lack of knowledge and poor patient

education being the most salient factors.

Conclusion

As public health campaigns can significantly contribute to

raising awareness about cervical cancer, our study provides a

basis for designing such a campaign in Serbia. Misconcep-

tions in knowledge about cervical cancer and screening need

to be addressed through an adequate public health campaign.

The campaign will need to be followed by education of

health professionals involved in providing health care to

women and the improvement of health services. Study

findings will also be used to inform and facilitate the change

in the government’s policy regarding cervical screening.

Acknowledgments

The study was funded by the Program for Appropriate

Technology in Health (PATH) through the Alliance for

Cervical Cancer Prevention.

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