Cervical cytology screening: Knowledge Attitudes and Behaviour of public Health Midwives in an urban district in Sri lanka

The present day practice is to combine cervical cytology with HPV DNA testing in the screening of cervical carcinoma and it generates good results compared to cervical cytology alone. Visual inspection of the cervix has re-emerged as a screening tool for low resource settings, despite its limited specificity, it is economical and provides immediate results4, 5. Visual inspection can be done with the application of acetic acid or Lugol’s iodine and it is referred to as Visual Inspection with Acetic Acid (VIA) or Visual Inspection with Lugol’s Iodine (VILI).

The main aim of screening for cervical carcinoma is to reduce the incidence of cervical carcinoma by detecting and treating pre-cancerous lesions. A secondary aim is to detect the invasive carcinomas at an early stage, which might improve the prognosis.
Schiller introduced the first method of cervical cancer screening in 1930s. He visually inspected the cervix after application of Lugol's iodine and it was described as the Schiller's test 3 .
The present day practice is to combine cervical cytology with HPV DNA testing in the screening of cervical carcinoma and it generates good results compared to cervical cytology alone. Visual inspection of the cervix has re-emerged as a screening tool for low resource settings, despite its limited specificity, it is economical and provides immediate results 4, 5 . Visual inspection can be done with the application of acetic acid or Lugol's iodine and it is referred to as Visual Inspection with Acetic Acid (VIA) or Visual Inspection with Lugol's Iodine (VILI).
The National Health Service Cervical Screening Program (NHSCSP) of United Kingdom (UK) is widely recognized as one of the successful cancer prevention programs in the world 6 . The 20-65 year age group is screened at 3-5 yearly intervals. Nearly four million females are screened per year and from 2001 to 2002, the screening coverage is reported as 71% for 3-yearly screening and 82% for 5-yearly screening 7 .
In Sri Lanka cervical cytology screening is the established method for screening of cervical carcinoma, and is mainly carried out through the well woman clinics (WWC) based at Medical Officer of Health (MOH) clinics.
Females of 35-year age cohort are the special target population for cervical cancer screening at these clinics and women with negative test results are rescreened at 5-year intervals. The 35-year age cohort coverage with Pap smear testing is 25.5, 28.9 and 33.9 percent for the years 2011, 2012 and 2013 respectively 8 .
PHMM (Public Health Midwives) play a major role at the grass root level of the primary health care system in Sri Lanka. Traditionally these health workers focused only on midwifery, but now they have evolved into a professional cadre, playing a role in preventive health covering many aspects other than midwifery. Their services are immensely valued in rural settings where health resources are scarce 9 . Therefore their knowledge, attitudes and behavior on cervical cytology screening was assessed in order to improve their services as well as to make improvements in health policies.

MATEriAlS AND METHODS
A descriptive cross-sectional study was carried out in 274 PHMM, attached to the MOH offices in Galle district. A total of 40 PHMM those who did not give consent for the study and those who were on leave on the date of data collection were excluded from the study.
PHMM were approached at the monthly conferences of each MOH office and were invited to participate in the study. The objectives of the study were explained and informed written consent was obtained. Data were collected using a pre-tested self-administered questionnaire. The content of the questionnaire was based on the recommendations of the family health bureau of Sri Lanka. The knowledge on screening methods for cervical cancer and knowledge on various aspects of cervical cytology screening (target group, interval of screening and benefits of screening) were assessed. The question assessing knowledge on screening methods was given a score of 40 and the questions assessing target group, interval of screening and benefits of screening were assigned a score of 20 per each question (total score=100). PHMM were categorized into above average, average and below average levels of overall knowledge if their score is >60, between 40 and 60 and <40 respectively.
Results were assessed for significant associations between overall knowledge and age category of the participant, educational level, total years of service, years of service in the field and additional training.
Responses to each attitudinal statement were assigned a score from 1 to 5 with those with favourable attitudes being assigned a higher score. Considering the scores for all attitudinal statements the PHMM were categorized into having 'favourable' (score 10 and above) and 'unfavourable' (score less than 10) attitudes towards cervical cytology screening program.
Ethical clearance was obtained from the Ethics Review Committee of the Faculty of Medicine, University of Ruhuna, Sri Lanka.
Data analysis done with calculating proportions, interquartile ranges and mean.t-test was used to test quantitative data with normal distribution. Chi-squared tests were used to determine whether there is a significant difference between the expected frequencies and the observed frequencies.
rESulTS Three hundred and fourteen PHMM were approached and only 274 of them participated the study. Hence the response rate was 87%.
The mean years of service as a PHM was 17.2 years and mean years of service in the field of 15.7 .The service in the field of the PHMM ranges from 1-34 years. Majority of the participants had total  There is a significant increase in knowledge with the educational level of the PHMM. Awareness regarding HPV typing as a cervical screening tool is generally poor among the PHMM. There is overall positive attitude towards cervical cytology screening among the PHMM. A significant number of PHMM had not undergone cervical cytology screening themselves.
As the cervical cytology is the established method of screening for nearly thirty years and PHMM being the key persons involved in recruiting individuals for cervical cytology screening they are expected to possess 100% knowledge in this aspect.
Knowledge on other tests used in cervical cancer screening i.e. testing for HPV DNA and VIA is low but it is expected to have much more knowledge on HPV DNA as an emerging method in screening for cervical cancer.
In comparison to a study done in Uganda among medical workers where less than 40% knew about the eligibility for Pap smear and screening interval 12 , our study population, the knowledge on interval of screening was closer to 100% but the knowledge on target group and benefits of screening is not very satisfactory.
Few had the misbelief that cervical cytology screening itself cures cervical cancers, which result in a false reassurance for those who undergo the procedure.
There was a positive attitude on their part in recruiting individuals for cervical cancer screening.
Incidence of cervical cancer screening among health workers varies, study done in in West Africa 10 reported 18.4% and in Uganda, 19% 12 . In a study done in Sri Lanka in 2012 revealed that, 73.4% of healthcare workers have never had a Pap smear 11 . In our study only one third of the health workers who are more than 35 years age group (35.7%) has not undergone cervical cytology screening. Lack of interest, not feeling at risk, carelessness and being unmarried are some of the reasons.
Almost all of those who had undergone cervical cytology screening were satisfied with the procedure, which may indicate the high quality of care and the standards of the procedure.
There was no significant associations between overall knowledge and the age, total years of service, years of field service or the additional training they had. There was a significant increase in knowledge with higher levels of education of the participant.

CONCluSiON AND rECOMMENDATiONS
A vast majority of the PHMM had an above average overall knowledge on cervical cytology screening and identified it as a screening method.