PRACA ORYGINALNA

ORIGINAL ARTICLE

CERVICAL CANCER – CAUSES AND PREVENTION OF HPV INFECTIONS IN THE OPINIONS OF YOUNG POLISH WOMEN: A CROSS-SECTIONAL SURVEY

RAK SZYJKI MACICY – PRZYCZYNY ORAZ PROFILAKTYKA ZAKAŻEŃ HPV W OPINIACH MŁODYCH POLEK: PRZEKROJOWE BADANIE ANKIETOWE

Artur Kotowski1, Maja Kotowska2, Aleksandra Warzyszyńska2, Iwona Szymusik3, Katarzyna Kosińska-Kaczyńska3, Andrzej M. Fal4

1MEMBER OF POLISH ASSOCIATION FOR GOOD CLINICAL PRACTICE GCPPL, WARSAW, POLAND

2STUDENTS SCIENTIFIC CIRCLE, II FACULTY OF MEDICINE, WARSAW MEDICAL UNIVERSITY, WARSAW, POLAND

3I CHAIR AND DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, WARSAW MEDICAL UNIVERSITY, WARSAW, POLAND

4CARDINAL STEFAN WYSZYŃSKI UNIVERSITY, WARSAW, POLAND

Abstract

Introduction: Cervical cancer is an important issue of gynecologic oncology. The awareness of this disease, the attitude towards HPV vaccination and cytological screening play an important role in decreasing morbidity and mortality due to cervical cancer.

The aim: To assess the various aspects of knowledge regarding cervical cancer, risk factors for this disease, the role of HPV infection and the attitude to primary (vaccination) and secondary (cytological screening) prevention among young women.

Materials and methods: The study was performed using CAWI method based on original questionnaire in electronic form. Online completing of the survey was voluntary and anonymous.

Results: The study was conducted in a group of 2058 women aged 19-33. In total 98.4% of respondents came across the term “cervical cancer”, 84.1% knew that cervical cancer could be prevented and the following were identified as the main risk factors: cervical cancer in closest relatives (85.3%) and HPV infection (81.9%). Although according to 82.0% of women HPV infection can be prevented by vaccination, only 18.4% of respondents were vaccinated. The main reason for non-vaccination was lack of knowledge about the availability of the vaccine (41.2%) and high price (32.0%). Of the unvaccinated people, 63.5% declare their will to be vaccinated in the future. Concerning secondary prevention, 98.6% of the respondents admitted that they knew the term “cytological examination”, 89.0% indicated that this examination detected the presence of pre-cancerous lesions, and according to 58.4% of respondents, this test should be performed after sexual initiation. Despite the fact that 80.5% of respondents confirmed the fact of beginning sexual activity (44.4% of them had more than 1 partner), 17.1% of the respondents admitted that they didn’t go to gynecologist yet. Approximately 84% of respondents believe that the amount of information on cervical cancer prophylaxis and HPV infections currently providing is insufficient.

Conclusions: The basic terms regarding primary (vaccination) and secondary (prophylactic tests) prevention of cervical cancer have been widely known. However, the knowledge about specific risk factors, sexual behaviors contributing to HPV infection and, consequently, the ability to self-identify as belonging to higher risk group is insufficient. It is justified to conduct educational activities regarding the assessment of risks related to cervical cancer addressed to young women. Together with education, HPV vaccination and secondary prevention programs require financial support.

Key words: cervical cancer, risk factors, prevention, HPV, vaccines, awareness

Streszczenie

Wstęp: Rak szyjki macicy jest istotnym problemem ginekologii onkologicznej. Swiadomość choroby, nastawienie do szczepień przeciwko HPV oraz profilaktycznych badań cytologicznych, odgrywają istotną rolę w redukcji zachorowalności i śmiertelności z powodu tej choroby.

Cel pracy: Ocena poziomu wiedzy na temat raka szyjki macicy (RSM), czynników ryzyka tej choroby, w tym roli zakażenia wirusem HPV oraz stosunku do profilaktyki pierwotnej (szczepienia) i wtórnej (cytologiczne badania przesiewowe) wśród młodych Polek.

Materiały i metody: Badanie wykonano metodą CAWI (Computer Assisted Web Interview) wykorzystując autorską, 27-pytaniową ankietę kwestionariuszową w formie elektronicznej. Wypełnienie ankiety było dobrowolne, anonimowe, wykonane online.

Wyniki: Badanie przeprowadzono w okresie 11.2018−01.2019 w grupie 2058 kobiet w wieku 19−33 lata. Z ogółu badanych, 98,4% respondentek zetknęła się z pojęciem rak szyjki macicy, 84,1% wiedziała że można zapobiegać wystąpieniu RSM, a jako główne czynniki ryzyka wskazano: występowanie RSM u najbliższych krewnych (85,3%) oraz zakażenie wirusem HPV (81,9%). Pomimo, iż według 82,0% kobiet można zapobiegać infekcji HPV poprzez szczepienie, jedynie 18,4% respondentek została zaszczepiona, głównym powodem nieszczepienia był brak wiedzy o dostępności szczepionki (41,2%) oraz jej wysoka cena (32,0%). Spośród osób niezaszczepionych, 63,5% deklaruje chęć zaszczepienia się w przyszłości. W zakresie profilaktyki wtórnej, 98,6% respondentek przyznało, że zna pojęcie badanie cytologiczne, 89,0% wskazało, że badanie to wykrywa obecność zmian przednowotworowych i RSM, a według 58,4% respondentek powinno być ono wykonane po inicjacji seksualnej. Pomimo iż 80,5% badanych potwierdziło fakt rozpoczęcia współżycia płciowego (z czego 44,4% zadeklarowało współżycie z ≥1 partnerem seksualnym), 17,1% respondentek przyznało, że nie było jeszcze u ginekologa. Około 84% badanych uważa, że ilość informacji na temat profilaktyki RSM i zakażeń HPV docierająca obecnie jest niewystarczająca.

Wnioski: Podstawowe pojęcia z zakresu profilaktyki pierwotnej (szczepienia) i wtórnej (badania profilaktyczne) raka szyjki macicy okazały się powszechnie znane. Natomiast wiedza na temat poszczególnych czynników ryzyka raka szyjki macicy, zachowań seksualnych sprzyjających zakażeniu HPV i w konsekwencji umiejętność identyfikacji siebie w kontekście przynależności do grupy podwyższonego ryzyka jest niewystarczająca. Reasumując: zasadne jest prowadzenie działań edukacyjnych dotyczących oceny ryzyk związanych z RSM kierowanych do młodych kobiet. Równolegle z edukacją, w celu zwiększenia dostępności, wsparcia finansowego wymagają programy szczepień przeciwko HPV i profilaktyki wtórnej.

Słowa kluczowe: rak szyjki macicy, czynniki ryzyka, profilaktyka, HPV, szczepienia, świadomość

Wiad Lek 2019, 72, 3, 327-335

INTRODUCTION

Cervical cancer is an important issue of gynecologic oncology. According to the GLOBOCAN report, 570,000 new cases of this type of cancer were reported worldwide in 2018 and the number of deaths exceeded 300,000 [1]. This problem is particularly conspicuous in African countries (incidence rate is 40/100,000 and mortality rate is 20/100,000). Both indices are much lower in European countries, but there is a clear difference between the countries of Central and Eastern Europe and Western Europe (morbidity rate: 16/100,000 vs. 6.8/100,000, respectively and mortality rate 6.1/100,000 vs. 2.1/100,000, respectively).

Cervical cancer is currently the sixth most common (accounting for 4.0%) malignant tumor among women. In recent years, there has been a steady, slow downward trend in the incidence of this cancer. According to the latest reports from the National Cancer Registry (NCR) in Poland, in 2010 there were 3078 new cases (morbidity rate: 10.3/100,000) and 1,735 deaths (mortality rate: 5.1/100,000) reported [2].

Among the EU countries Poland is distinguished by a higher mortality rate due to cervical cancer, which results from the late diagnosis; app. 40% of patients are diagnosed in the advanced stage, and only 27% of women regularly performed cytological tests (Pap smears) [2]. The survival analysis indicates that as a country we have one of the lowest 5-year relative survival rates (app. 54.0%) as compared to European countries (app. 67.0%) [2]. In majority of cases, carcinogenesis in cervical cancer is associated with chronic human papilloma virus (HPV) infection [3]. Other risk factors include maintaining sexual contact with multiple partners and early age of beginning sexual activity, immune disorders and long-term smoking. Likely factors such as: long-term use of hormonal contraception, vaginitis (inflammation of the vagina), some sexually transmitted diseases (STDs) (e.g. chlamydiasis, trichomoniasis, infection of herpes simplex virus 2 [HSV2]) may accelerate the process of carcinogenesis [4]. An established way to reduce the risk of developing cervical cancer is anti-HPV vaccination, which should be done before sexual initiation. There are currently three vaccines available in the EU: 2-valent, 4-valent or 9-valent vaccine that can be used as part of routine vaccinations for girls aged 11−12 and women up to 26 years of age, previously unvaccinated or those who have not completed the full, 3-dose vaccination schedule [5]. Unfortunately, the availability of vaccinations against HPV in Poland is hampered by the lack of funding in the childhood immunization programs, which is only partially compensated through preventive self-governmental programs.

In Poland, the subject of cervical cancer has been present in mass media for years. Since 2007, the annual edition of the European Cervical Cancer Prevention Week has been organized, a ministerial program of free-of-charge prophylactic tests is being conducted, there are also internet portals addressed to young women: www.hpvukobiet.net.pl, www.jestemprzytobie.pl, www.zaszczepsiewiedza.pl, www.koalicajacervicalcancer.pl and numerous groups in social media. Unfortunately, there is a lack of feedback from the addressees of educational messages, including the answer to the question to what extent available information meets information needs and how it translates into knowledge/awareness of cervical cancer. In Polish publications assessing knowledge and awareness of cervical cancer, the conclusions about the low level of knowledge and the lack of awareness of disease risk and the possibilities of prevention are mentioned [6−11].

This study aims to assess the level of knowledge about cervical cancer and to contribute to the understanding of young women’s attitudes towards cervical cancer and disease prevention.

THE AIM

The aim of the study was to assess the level of knowledge of young women about cervical cancer and risk factors for the development of this disease, in particular the role of HPV and the possibility of prophylactic vaccination, as well as the assessment of knowledge and attitude of young women to cytological screening.

MATERIALS AND METHODS

The study was conducted using the CAWI (Computer Assisted Web Interview) based on original questionnaire, in which the respondents were asked to complete the survey in electronic form online. The questionnaire was prepared with use of Google Forms tool, placed between November 2018 and January 2019 on popular discussion groups in one of social media platform. It contained 27 questions, which covered the following areas: knowledge, primary prevention – vaccinations, secondary prevention – screening based on cytological tests, sexual behavior description and expectations regarding information on cervical cancer and HPV prophylaxis. Closed questions were asked with a nominal scale (YES/NO/DON’T KNOW), multiple-choice semi-open questions and Likert scale questions from 1 to 10 points, where the value of “1” was the minimum level, and 10 points – the maximum level.

Statistical analysis

All statistical calculations were carried out using the StatSoft Inc. statistical package STATISTICA (2014) (data analysis software system), version 12.0, www.statsoft.com and the Excel spreadsheet. In case of the two related variables model, Student’s t-test or the Wilcoxon matched-pairs signed-ranks test was used. Chi-square independence tests were used for qualitative variables. In order to determine the relationship, power and direction between variables, the correlation analysis was used by calculating the Pearson and/or Spearman correlation coefficients. In all calculations, p = 0.05 was assumed as the level of significance.

RESULTS

The study was conducted in a group of 2058 women aged 19-33. Baseline characteristics of the studied population in terms of age, place of residence, occupational situation (school/work), health-related behaviors (smoking) and sexual behaviors (number of sexual partners), are presented in Table I.

In the study population, almost all respondents (98.4%; n=2025) came across the term “cervical cancer”, 81.9% (n=1685) indicated that the cause of cervical cancer may be HPV infection and 84.1 % (n=1731) agreed with the statement that the occurrence of this disease can be prevented.

Participants of the study were asked to make a self-assessment of knowledge about cervical cancer on a scale of 1-10 points. In the whole study population, an average of 5.7 points (SD 2.2, median 6.0) was obtained, where 18.9% of the respondents indicated the level in the range of 1-3 points (lower tertile recognized by the authors as low level of knowledge), 57.7% in the range of 4-7 points (middle tertile, considered as moderate level) and 23.3% in the range >8 points (upper tertile, high level) (Fig. 1).

To the question: “What do you think may be a risk factor for cervical cancer?” the highest percentage of respondents indicated cervical cancer diagnosed in closest relatives (85.3%; n=1755) – not a significant risk factor and HPV infection (77.7%; n=1600). The early age of sexual initiation pointed out every fourth respondent. The distribution of responses in the whole studied population is shown in Fig. 2.

The relation between self-assessment of own knowledge about cervical cancer with the risk factors for the development of cervical cancer indicated by the respondents was analyzed. Respondents who indicated as a risk factor the occurrence of cervical cancer in close relatives and recurrent genitourinary infections – which in fact are not risk factors [4] – assessed their level of knowledge about cervical cancer statistically significantly lower compared to individuals who did not indicate these risk factors (p=0.0001). On the other hand, women who indicated the following risk factors: HPV infection (p=0.01), early sexual initiation (p=0.01), many sexual partners (p=0.01), age >50 years (p=0.0114), alcohol consumption (p=0.0001) and smoking (p=0.0001) assessed their level of knowledge about cervical cancer statistically significantly higher compared to individuals who did not indicate these risk factors (Table II).

There was no statistically significant correlation between the identification of cervical cancer risk factors and the age and place of residence of surveyed women.

Respondents (n=430), who in the question about cervical cancer risk factors indicated all the following: HPV infection, early age of sexual initiation and many sexual partners, e.g. risk factors well known from the literature to correlate with cervical cancer [4] showed, that their average declared level of knowledge about cervical cancer is 7.1/10 points (median 8.0) and for other women (n=1628) 5.3/10 points (median 5.0) and this difference is statistically significant (p = 0.0001).

When analyzing the level of awareness of cervical cancer risk factors in the study population, it turned out that only 15.7% (n=324) of women answered “yes” to the question: “Are you at higher risk of cervical cancer?”, 55.9% (n=1151) respondents answered “no”, and 28.3% (n=583) were unable to give a precise answer. In the group of women who declared having 4 and more sexual partners, i.e. in the individuals who should be included in the group of higher risk of cervical cancer (n=385), the highest percentage were those who believed that they do not belong to this high risk group. Also among women non-vaccinated against HPV and smokers, the highest proportion were those believing they were not at high risk.

The characteristics of women in terms of self-assessment of belonging to cervical cancer risk group and selected risk factors are presented in Table III.

Primary prophylaxis – vaccinations in the studied population

To the question: “Have you been vaccinated against HPV?”, 18.2% (n=374) of respondents answered positively, while the negative answer was given by 68.0% (n=1399) of the respondents. The most common incentive/vaccination proposal came from parents (58.8%; n=220), pediatricians (15.8%; n=59), gynecologists (6.2%; n=23) and other people (19.2%; n=72).

Analysis of the declared level of knowledge among women vaccinated against HPV showed a statistically significant higher average in relation to the whole studied population (6.3/10 points vs 5.5/10 points, p=0.0001). As the reason for not-vaccinating, the respondents showed the lack of knowledge about the existence/availability of the vaccine (41.2%; n=577) and its high price (32.0%; n=447). The distribution of responses in the studied population is shown in Fig. 3.

Interestingly, asking unvaccinated individuals (n=1399) “Would you vaccinate against HPV in the future?”, 63.5% (n=1063) of respondents answered in the affirmative, expressing a willingness to vaccinate, only 7.0% responded negatively (n=118) and 29.5% (n=493) women answered: “I do not know”. People, who as the reason for not-vaccinating indicated a high price, were asked: “If you have not been vaccinated because of the high price of vaccination, what price would be acceptable for you?” In response to this question, women indicated PLN 256.6 as the average acceptable price for vaccination (SD PLN 196.0; median PLN 200.0). In the study group, only 8 women indicated the need for a full refund of vaccination as a condition for joining vaccinations.

Secondary prophylaxis – cytological tests

The main goal of prophylactic cytological examination according to the respondents is detection of pre-cancerous lesions and detection of vaginal inflammation (91.6% and 48.5% respondents, respectively). The full structure of the answers to the question: “What does the cytological examination assess?” is shown in Fig. 4

In the whole analyzed population 17.1% (n=352) women indicated that they have not visited gynecologist yet, sporadic visits were declared by 19.0% (n=390) women, and visits once a year 29.4% (n=606) and more than once a year declared 34.5% (n=710) participants. To the question: “Did you have a Pap smear?” 62.4% of women answered in the affirmative, 36.3% responded negatively, while 1.3% were unsure of having this test. The vast majority of respondents (58.4%) indicated that the first cytological examination should be performed after sexual initiation. The full structure of the answers to the question “When should the first cytological examination be performed?” is shown in Fig. 5.

The analysis of the declared level of knowledge among women who have not yet visited the gynecologist (n=352) showed a statistically significant lower average in relation to the population who had at least one gynecological visit (n=1706) (5.0/10 points vs. 5.8/10 points, p=0.0001).

In total 85.3% of the respondents answered that the amount of information on cervical cancer and HPV prophylaxis currently providing is insufficient.

Discussion

In presented study, including one of the largest groups of young women in Poland [12-17] ever, in which the knowledge of cervical cancer, risk factors as well as primary and secondary prevention was tested, the CAWI method was selected using a ready-made tool in the form of a Google form (https : //www.google.com/intl/pl/forms/). Thanks to the widespread access to the Internet, also in rural areas the online research is becoming a more and more popular research method. According to the CBOS report 2018, access to Internet in young people population (<34 years) amounted to 96.0%, while according to educational level it was 76.0% and 92.0% for individuals with secondary and higher education, respectively [18]. The distribution of respondents in presented study (14.9% people were living in rural areas and 100% were ≤33 years) confirms the lack of systemic bias of studied sample by limiting the scope of the research tool.

Poland is a country with a higher incidence (+ 15%) and higher mortality (+ 70%) due to cervical cancer compared to the average level in EU countries [2]. This is associated with a lower, compared to other countries, rates of early diagnosis of this disease due to lower awareness of young women about cervical cancer risk factors, lack of conviction about the need to participate in cytological screening and low rate of HPV vaccination [2,19-21]. These observations were confirmed in earlier studies (Sawaryn D 2011, Ulman-Włodarz I 2011, Cichońska M 2012, Pacewicz M 2012, Baran W 2013, Szykuła A 2013, Kalinowski P 2014, Mędrela-Kuder E 2014, Stefanek A 2014, Leszczyńska K 2015, Gawron Ż 2016, Sulima M 2016, Jankowska P 2017) [5-16,18,22].

In presented study, as many as 85.3% of respondents indicated the occurrence of cervical cancer in close relatives as a risk factor for the disease (for which a definite causal relationship with the development of cervical cancer was not described in the literature). At the same time, the well-recognized risk factors for this disease, such as HPV infection, many sexual partners and an early age of sexual initiation were significantly less frequently indicated, by 77.7%, 47.2% and 25.9% respondents, respectively. Higher rates in terms of a large number of sex partners (68.0%) and early sexual initiation (52.0%) as risk factors for cervical cancer were also reported by Sulima et al [22].

Among all respondents, 58.4% indicated the time of sexual initiation as the recommended beginning of prophylactic cytological tests. At the same time, approximately 17.0% of the surveyed women confirmed that they have had no visit in gynecologist yet, although 44.4% of the entire analyzed population admitted to having sex with two or more partners. The obtained result indicates a discrepancy between theoretical knowledge and behavior in practice and should be an important element of future educational campaigns. Preventive screening test is an extremely important instrument having a direct impact on the increase of detection of cervical cancer in the early stages and, as a consequence, increasing the chances for patient to be cured/prolong life. In countries that successfully implemented preventive tests, a systematic decrease in mortality was observed. In Sweden in 1965, the incidence of cervical cancer was 20 per 100,000 women, while in 2012 it dropped to 6.5 per 100,000. The number of women reporting for Pap smears increased at the same time to 82% [23]. In the United Kingdom, a 74% drop in the mortality rate due to cervical cancer has been noted over the past 40 years (24% in the last decade), among others because women have been persuaded to participate in the cervical cancer prevention program – participation in screening programs currently reaches up to 74% women [24].

In Poland, recognizing the legitimacy of population prophylaxis, in 2005 the Act introducing the National Program for Counteracting Cancer Diseases in 2006-2015 was adopted. In spite of information and education activities, media campaigns and personal invitations for testing, it failed to be successful in the form of decreasing morbidity and mortality rate due to cervical cancer [25,26]. The percentage of women qualifying for screening and participating in the program was 21-23% of which only approx. 7% applied thanks to the received personal invitation (complete data is unknown due to the lack of registers and participation of the private gynecological services market) [27]. Undoubtedly, it is necessary to thoroughly analyze the reasons for the lack of success of the Program in order to propose other, more effective tools leading to the increase of awareness and encouragement for preventive examinations.

Due to the prevalence of HPV, which is also the most common cause of sexually transmitted infections and the proven association between HPV infection and cervical cancer, WHO recommends prophylactic vaccination, which should be performed before sexual activity, preferably between 11 and 12 years of age. In Poland, vaccinations against the human papillomavirus (HPV) are included in the Protective Vaccine Program for 2019 in the category of “Recommended vaccinations”, which means that they are not financed from the budget of the Ministry of Health [28]. Undoubtedly, high costs are a barrier to the generalization of vaccinations (in presented study 32% of respondents indicated the price as factor of not-vaccination against HPV), but other reasons indicated by the respondent included lack of knowledge about the existence of the vaccine (the highest percentage) (41.2%) and lack of belief in effectiveness (8.4%) as well as a risk of post-vaccination complications (9.2%). The positive thing is that by asking unvaccinated persons about their willingness to vaccinate in the future, over 63.0% of respondents answered in the affirmative. An important factor contributing to higher vaccination rate is the increase in the awareness of parents, who according to our study in 58.8% cases encouraged their children to vaccinate. A similar recommendation was issued by Ganczak et al. highlighting the need to educate parents [29]. The average, acceptable price level for all vaccinations indicated by respondents is approximately PLN 256.0. In terms of financing, free HPV vaccines offered by certain local governments within the framework of health promotion and preventive programs may be supportive.

Lack of awareness of the existence of vaccinations in the studied population is undoubtedly an important element of future educational activities. Evidence of the positive effect of educational activities was observed in many countries, including Denmark, where the level of HPV vaccination in 2018 was 73% [30]. It seems that a good channel to reach the target group could be social media, which is also confirmed by the wide participation of young women in our study, conducted via Internet.

CONCLUSIONS

1. Basic terms regarding cervical cancer, primary (vaccination) and secondary (prophylactic examinations) prevention have been well-known in the study population.

2. Knowledge about individual risk factors of cervical cancer and, consequently, the ability to identify oneself in the context of belonging to the group of higher risk is insufficient and requires improvement.

3. Due to the discrepancy between theoretical knowledge and behavior in practice, it is important to encourage women to implement appropriate pro-health attitudes, including performing regular cytological screening tests and participation in vaccination.

4. HPV vaccination rate should be increased thanks to educational activities aimed at young women and parents of teenagers, informing about the availability of the vaccine and the benefits of its use, and by effectively reducing the price of vaccination and/or free access within health programs.

5. Due to the lack of information on cervical cancer and principles of prevention of this disease reported by the respondents, an educational campaign using social media should be considered.

Acknowledgments

The authors acknowledge the medical writing assistance of Dariusz Stencel, MD, from DaFonte Dr Dariusz Stencel, during the development of this manuscript.

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Conflict of interest

There is no conflict of interest

Corresponding author

Artur Kotowski

Member of Polish Association for Good Clinical Practice GCPPL,
Warsaw, Poland

e-mail: kotowski.a@gmail.com

Received: 30.01.2019

Accepted: 25.02.2019

Table I. Baseline characteristics of studied population.

Studied group

(N=2058)

Age

mean (SD)

22.8 (3.8)

range

19.0-33.0

median

22.0

Age (intervals)

19-20

763 (37.1%)

21-24

731 (35.5%)

25 and above

564 (27.4%)

Place of residence

countryside

307 (14.9%)

city <10,000

102 (5.0%)

10,000-100,000

479 (23.3%)

>100,000

1170 (56.8%)

School/work

college

1295 (62.9%)

work

644 (31.3%)

other

119 (5.8%)

Smoking

no

1311 (63.7%)

occasionally

499 (24.2%)

yes

248 (12.0%)

Number of sexual partners

not yet sexually active

402 (19.5%)

1

742 (36.1%)

2-3

529 (25.7%)

4-5

186 (9.0%)

more than 5

199 (9.7%)

Fig. 1. Subjective respondents assessment of the level of own knowledge about cervical cancer on a scale of 1-10 points.

Table II. Correlation between the answer to the question: “How would you rate your knowledge about the occurrence of cervical cancer” and the indicated risk factors.

Answer: This is not a risk factor

Answer: This is a risk factor

P-value

Occurrence of cervical cancer in relatives

0.0001

average level of knowledge in self-evaluation (SD)

6.3 (2.3)

5.6 (2.2)

median

7.0

6.0

Age > 50 years

0.0114

average level of knowledge in self-evaluation (SD)

5.6 (2.3)

5.8 (2.1)

median

6.0

6.0

Alcohol consumption

0.0001

average level of knowledge in self-evaluation (SD)

5.6 (2.2)

6.4 (2.2)

median

6.0

7.0

Smoking

0.0001

average level of knowledge in self-evaluation (SD)

5.5 (2.2)

6.0 (2.2)

median

5.0

6.0

The use of hormonal contraception

0.1094

average level of knowledge in self-evaluation (SD)

5.6 (2.2)

5.8 (2.2)

median

6.0

6.0

Early age of sexual initiation

0.0100

average level of knowledge in self-evaluation (SD)

5.3 (2.1)

6.8 (2.0)

median

5.0

7.0

Many sex partners

0.0100

average level of knowledge in self-evaluation (SD)

5.0 (2.1)

6.4 (2.1)

median

5.0

7.0

HPV infection

0.0100

average level of knowledge in self-evaluation (SD)

4.3 (2.0)

6.1 (2.1)

median

4.0

6.0

HIV infection

0.9627

average level of knowledge in self-evaluation (SD)

5.7 (2.2)

5.7 (2.4)

median

6.0

6.0

Recurrent genitourinary infections

0.0001

average level of knowledge in self-evaluation (SD)

5.8 (2.2)

5.4 (2.2)

median

6.0

5.0

Fig. 2. Risk factors for cervical cancer identified by respondents in studied population.

Fig. 3. Reasons for not-vaccinating against HPV.

Table III. Comparative characteristics of women declaring/denying being at high risk of cervical cancer.

I am in a high-risk group

YES

(N=324)

NO

(N=1151)

DON’T KNOW

(N=583)

Number of sexual partners

I didn’t have intercourse yet

39 (9.7%)

250 (62.2%)

113 (28.1%)

1

82 (11.1%)

454 (61.2%)

206 (27.8%)

2-3

87 (16.4%)

272 (51.4%)

170 (32.1%)

4-5

46 (24.7%)

94 (50.5%)

46 (24.7%)

More than 5

70 (35.2%)

81 (40.7%)

48 (24.1%)

Have you been vaccinated against HPV?

yes

59 (15.8%)

238 (63.6%)

77 (20.6%)

no

223 (15.9%)

787 (56.3%)

389 (27.8%)

don’t know

32 (12.3%)

117 (44.8%)

112 (42.9%)

I’m in the process of vaccination

10 (41.7%)

9 (37.5%)

5 (20.8%)

Do you smoke?

no

178 (13.6%)

796 (60.7%)

337 (25.7%)

occasionally

76 (15.2%)

267 (53.5%)

156 (31.3%)

yes

70 (28.2%)

88 (35.5%)

90 (36.3%)

Fig. 4. The structure of the answers to the question: “What does the cytological examination assess?”

Fig. 5. The distribution of the answers to the question “When should the first cytological examination be performed?”