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Knowledge of cervical cancer and Pap smear among Uyghur women from Xinjiang, China
- Guzhalinuer Abulizi1Email authorView ORCID ID profile,
- Tangnuer Abulimiti1,
- Hua Li†1,
- Guzhalinuer Abuduxikuer†1,
- Patiman Mijiti†1,
- Su-Qin Zhang2,
- Ayinuer Maimaiti3,
- Muyasier Tuergan†3,
- Ayiguli Simayi4 and
- Miherinisha Maimaiti5
© The Author(s). 2018
Received: 8 June 2016
Accepted: 7 January 2018
Published: 17 January 2018
Cervical cancer is a significant public health issue in Xinjiang China. In order to provide scientific basis for cervical cancer intervention in Xinjiang, women’s knowledge of cervical cancer was investigated in this study. Besides, relations between Uyghur women’s awareness and their age, educational background, yearly household were evaluated.
Questionnaire survey was conducted to 7100 Uyghur women from Karkax Hotan and Payzivat Kashgar during 2008 and 2009. Women aged 21 to 70 years, had sexual activity, no history of cervical lesion or cervical cancer were considered to be eligible to the study. Information include participants’ socio-demographic background, personal data, awareness about Pap smear, about cervical cancer and HPV, sources of information acquisition was investigated.
65.1% of the 7100 respondents with primary education level, and 95.0% participants were farmers. Only 7.4% had undertaken Pap smears before, not aware of the importance of the test (97.4% of 7100) was the main reason for not performing Pap smears. 29.3% of total participants had heard about cervical cancer, and only 0.14% (10 out of 7100) had heard about HPV. Top three route of knowledge acquire were television advertises (39.1%), neighbors (21.0%) and health care providers (15.0%). Women younger than 40 years, with higher educational levels and higher income had better awareness of cervical cancer and more willing to accept regular Pap smears.
Uyghur women in Xinjiang had poor knowledge of cervical cancer and HPV infection. Low awareness of women was associated with less household income and lower educational levels. TV shows and education from health care providers may increase women’s participation in cervical cancer control and prevention.
Cervical cancer is the most common genital tract malignancy in women and is the second most common cancer in women after breast cancer, with an estimated 530,000 new cases diagnosed each year . During the past 4 decades, cervical cancer incidence and mortality have declined significantly, primarily in western countries, because of the widespread use of the Papanicolaou (Pap) test to screen for cervical abnormalities. Indeed, the rate of decline in cervical cancer incidence and mortality seems to have decreased and has now reached a plateau. However, high incidences of cervical cancer are still being observed and remain a significant problem in developing countries and resource-insufficient areas such as Africa, Asia and Central and South America [2–5].
China is one of the Asian countries with high cervical cancer incidence and mortality rates. According to recent data from a network of 10 Chinese cancer registries, the cervical cancer incidence in China is estimated to be below 4/100,000 [1, 4]. Over the past 30 years, cervical cancer incidence and mortality have decreased steadily in China due to the development of the Pap test and the implementation of screening programs . However, in some remote and poverty-stricken areas, including the Xinjiang Uyghur Autonomous Region, cervical cancer incidence and mortality remain high [7–9].
The Xinjiang Uyghur Autonomous Region is located at the northwest border of China. It is the key transport junction of the ancient Silk Road and is inhabited by people from four world cultural systems with long histories, i.e., China, India, Islam and Rome (Greek). These people have formed a large, mixed community of various nationalities, including Uyghur, Han, Kazak, Hui, Kyrgyz, Mongol, Xibe, Manchu, Uzbek and Russian in Xinjiang . Their economic and, cultural backgrounds play an important role in every detail of Uyghurs’ lives, including marriage, birth, life habits, attitudes and health consciousness . Reports from 2007 indicated that healthcare accessibility in west China was insufficient due to geographical conditions and economic underdevelopment. Xinjiang is mainly a mountainous area, and the population is dispersed over wide areas, making travel inconvenient. Poverty is also a factor restricting the effective utilization of healthcare services. However, the implementation of a New Rural Co-operative Medical System in 2011 has resulted in dramatic improvements in farmers’ medical care. Now, subsidies from state revenue to the west have reached 80%, and the coverage of social security programs for the agricultural population has reached 96.78% [12, 13].
Estimates have shown that the prevalence of cervical cancer among Uyghur minorities is 459/100,000–590/100,000, and the cervical cancer mortality rate is 17.78/100,000. These values are clearly higher than those for the Han, Kazak, Mongol, and Kyrgyz, who also live in Xinjiang. Uyghur cervical cancer patients are younger than patients from other nations. The cervical cancer mortality rate among the Uyghur is the highest of all minority groups in China [7, 8, 14, 15]. In previous studies, a questionnaire was used to survey Xinjiang Uyghur women with cervical cancer, and these studies showed that these women have poor knowledge of cervical cancer and the Pap smear test; many of the surveyed women had never undergone a gynecological examination, and HPV was completely unknown to them [16, 17]. These factors most likely resulted in the steady, high incidence of cervical cancer in Uyghur women . Therefore, cervical cancer is an extremely important public health issue, and reducing the incidence and mortality is urgently required.
The lack of knowledge regarding cancer screening may be a reflection of general poor health education in China. Therefore, comprehensive health education programs are more likely to be beneficial in tackling this problem than disease-specific programs. While numerous studies have conducted population-based analyses of cervical cancer and HPV awareness and knowledge [19–25], virtually no research has been performed exclusively among Uyghur women. In the present study, we examined cervical cancer knowledge and its relationship to educational background and yearly household income among Uyghur women in the Hotan and Kashgar regions of Xinjiang, China, to provide a basis for an educational intervention targeting cervical cancer in Xinjiang.
Samples and data collection
We conducted a cross-sectional study of Uyghur women in the cities of Hotan and Kashgar in 2008 (May to September) and 2009 (June to August) to evaluate their cervical cancer knowledge, and it had taken 8 months to complete the whole survey. The total number of women aged 15–64 were about 193,000 in Karakax, Hotan and 14,000 in Payzivat, Kashgar based on rough estimated data. A total of 5495 women from Hotan and 2313 women from Kashgar were enrolled and accepted the questionnaire survey. Of these, 5000 and 2100 qualified questionnaires were collected. The response rate was 91.0 and 90.8%, respectively. All participants were approached at their homes by trained recruiters, including 4 physicians and 5 healthcare workers. The inclusion criteria were Uyghur women aged 21 to 70 years with a history of sexual intercourse and no diagnosis of cervical cancer or cervical lesions.
The questionnaire was designed in Chinese (Additional file 1) and was translated into Uyghur by the doctors who performed the interview, and the interview was performed during regular, routine primary care home visits.The questionnaire was divided into the following six sections: socio-demographic background, respondents’ personal data, Pap smear knowledge, cervical cancer awareness, HPV awareness, sources of cervical cancer and HPV information, and reasons for not undergoing Pap smears. This study was approved by the Ethics Committee of Xinjiang Medical University, and every participant provided their written informed consent in the Uyghur language to participate in this study. The ethics committee approved this consent procedure.
Each subject was asked demographic questions to collect information about her age, education, occupation, monthly household income, marital status, and education level as well as the number of pregnancies and number of children. Sexual history information was obtained, including age at first sexual intercourse.
Knowledge and attitude toward pap smears
Participants were asked whether they had ever had a Pap smear and why.
Knowledge regarding cervical cancer
Participants were asked whether they had ever heard of cervical cancer and the causes, signs and screening techniques for cervical cancer. Pap smear frequency and cervical cancer prevention knowledge were also obtained.
Data processing and statistical analyses were performed using SPSS 17.0 (IBM Corp, Armonk, NY, USA). Basic descriptive statistics and frequencies were analyzed for all variables. Differences in awareness of cervical cancer by educational level and yearly household income were compared using the χ2 test, and statistical significance was defined as P ≤ 0.05.
Five thousand four hundred ninety five women from Karasay Hotan and 2313 women from Kezilboy Kashgar were recruited to the study, qualified questionnaire was ontained from 5000 and 2100 women, respectively, and the response rate was 91.0 and 90.8% for Hotan and Kashgar. Total of 7100 women were enroll to this study with a mean age of 42.4 years (21–70 years). The education statuses of the respondents were as follows: 11.3% illiterate, 65.1% elementary school education, 21.1% middle school education and 2.5% college and higher education. The majority of respondents were peasants (95.0%), and the remainder were government employees 2.4% (169), workers 1.4% (98), and other 1.2% (88). The yearly household income of <Ұ5000($758), Ұ5000($758)–10,000($1516), Ұ10,000($1516-)–30,000($4548), Ұ30,000($4548-)–100,000($15,159) and unable to estimate were 68.4% (4858), 24.7% (1755), 2.5% (174), 1.0% (73) and 3.4% (240), respectively.
Knowledge and attitudes toward pap smears
Awareness of cervical cancer
Sources of information about cervical cancer
The percentage of participants who had some knowledge of cervical cancer was 30.0% (2132 cases). The sources of information about cervical cancer, in order from highest to lowest reported frequency, were as follows: television (35.1%); neighbors, friends and relatives (30.1%); healthcare providers (12.0%); screening programs (11.8%); radio (5.6%); public lectures (2.4%); print media (2.1%); and network (0.9%). (Fig. 2).
Correlations between cervical cancer knowledge and age, educational level and income
Women’s knowledge of five items in different age groups
Relationship between cervical cancer knowledge and education level
Cervical cancer and HPV knowledge
None (n = 803)
Primary (n = 4621)
Secondary (n = 1498)
College (n = 178)
Total (n = 7100)
Heard about cervical cancer
Knew the cause of cervical cancer
Knew the signs of cervical cancer
Knew the significance of regular Pap smears
Had regular Pap smears before
Relationship between knowledge and yearly household income
Cervical cancer and HPV knowledge
Yearly household income
Ұ5000 (n = 4858)
Ұ5000–10,000 (n = 1755)
Ұ10,000–30,000 (n = 174)
Ұ30,000–100,000 (n = 73)
Unknown (n = 240)
total (n = 7100)
Heard about cervical cancer
Knew the cause of cervical cancer
Knew the sign of cervical cancer
Knew the significance of regular Pap smears
Had regular Pap smears before
The prevalence of cervical cancer among Uyghur women in China has remained high over the last 30 years. From 1976 to 2004, the prevalence of cervical cancer among Uyghur women was 590/100000, 459/100000 and 527/100000 [7, 8]. Because cervical cancer can be prevented by early detection and treatment, these rates are alarming and unacceptable. The excess mortality observed in Uyghur women is due in part to low Pap smear screening rates [7, 8]. Disparities in cervical cancer screening and outcomes are influenced by individual factors, including cultural beliefs, customs and habits, linguistic barriers, and socioeconomic status .
This study revealed some typical characteristics of Uyghur women living in rural areas. Most Uyghur women have a primary education and work as peasants with a low income. Older age, poverty and a low level of education were correlated with lack of awareness of cervical cancer and all other medical information. Of 7100 women, 2.59% knew the purpose of regular Pap tests. Many women had a Pap smear based on a doctor’s recommendation. This suggests that the majority of women did not know Pap smears were an available method for cervical cancer screening. The most common reasons for not undergoing Pap smears were no awareness regarding the importance, no symptoms and no money. Embarrassment, unavailability of transportation and fear of pain were other reasons that women did not undergo screening. In the two counties studied here, primitive medical facilities and a lack of knowledge among health providers regarding cervical cancer were the most likely factors impeding the participation of local women in screenings. Other cultural barriers may lead to negative opinions about screenings, including concern about exposing private body parts . When asked about their knowledge of cervical cancer, 6822 (96. 08%) women did not know the cause, 5328 women did not know the signs, and 5879 did not know any screening methods. Furthermore, only 7 women had heard about HPV, and only 3 knew that HPV was the cause of cervical cancer. These results show the grave lack of knowledge among Uyghur women regarding cervical cancer, and this lack of knowledge is associated with the high cervical cancer incidence and mortality in this population. Intra Uterine Devices and destiny were considered to be the main causes of cervical cancer. These beliefs may be related to the low educational level of the women. Some women believed that ultrasound pelvic examination could detect cervical cancer, and far fewer women knew that Pap smears and HPV tests were the primary screening methods. Local doctors and other health care providers are partly responsible for this misconception. Watching television was the respondents’ favorite pastime, and television is their best source for cervical cancer knowledge. This finding suggests that a greater number of health educational TV programs or advertisements should be produced in the future to enhance cervical cancer awareness. Statistically significant relationships between education level, cervical cancer knowledge and sex-related factors were found, and cervical cancer knowledge was related to household income.
Women have reported a need for information regarding the indications, benefits, and procedures of cervical cancer screening. Such information is effective at increasing primary screening rates . The factors that reduce participation in cervical screening programs are as follows: poor awareness of the indications and benefits of the cervical smear test, lack of knowledge of cervical cancer and its risk factors, fear of embarrassment and pain, poor understanding of cervical screening methods, and the need for additional information .
Little is known regarding the awareness of the risks of cervical cancer among Uyghur women. Our findings seem to coincide with the findings of several national surveys, which suggest that poor, less educated populations are less likely to use cervical cancer screening services [26, 29, 30].
Compared to several studies that assessed HPV awareness, the Uyghur women in our study had absolutely no awareness of HPV. Compared to the Klug et al. meta-analysis, this awareness was low . Numerous studies have found that awareness of HPV is extremely low among minorities, adolescents, and low-income groups [31, 32].
In conclusion, age older than 40 years, poverty and low educational levels are the key factors resulting in poor cervical cancer knowledge among Uyghur women, particularly those who live in the remote countryside. This study showed that several demographic, awareness and attitudinal factors are associated with a decreased likelihood of women utilizing cervical cancer screening. Although these factors are important to consider and policies can address all of them, resources that specifically target the factor most closely associated with uptake, namely, women’s lack of knowledge regarding cervical cancer and its prevention, should be the primary focus. Eliminating this barrier is paramount to achieving the goal of reducing cervical cancer incidence and mortality.
Uyghur women in China have poor knowledge of cervical cancer and HPV infection, which is associated with low household income and low educational levels. Education via TV and health care providers may improve compliance with programs aimed at cervical cancer prevention and treatment.
We would like to thank the doctors of Maternal and Children Hospital of Kashgar Payzivat county and Maternal and Children Hospital of Hotan Karakax county for their kindly assistance and cooperation.
The current study was funded by the National Natural Science Foundation of China (Grant number: 30860325).
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
G Abulizi made substantial contributions to study conception and design and provided the final approval of the manuscript version to be published. TA and HL were involved in drafting the manuscript or revising it critically for important intellectual content. G Abuduxikuer and PM analyzed and interpreted the data. SZ, AM, MT, AS, and MM acquired the data. Each author participated sufficiently in the work to take public responsibility for appropriate portions of the content and agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final manuscript.
Ethics approval and consent to participate
Written consent from each study participant was obtain before sample acquisition, and the study was approved by Ethnic Committee of the Affiliated Tumor Hospital of Xinjiang Medical University.
Consent for publication
The authors declare that they have no competing interests.
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