Summary

Objective:To compare the characteristics of women undertaking cervical cancer screening in Hong Kong (HK) and Beijing (BJ).

Design: Self-administered questionnaires.

Subjects: Chinese women aged 25-65 attending four primary care clinics in Hong Kong & Beijing.

Main outcome measures: Basic sociodemographics; knowledge, attitude and perceived risk on cervical cancer screening programme; experience on cervical smear; the reasons for not having regular cervical smear.

Results: 299 valid questionnaires were collected from Hong Kong (n=155, 56%) and Beijing (n=144, 44%). There was no significant difference detected in the routine cervical smear uptake rate between HK subjects (63.9%) and BJ subjects (57.6%) (p=0.24). More HK subjects than BJ subjects (HK=94% Vs BJ=85.4%, p=0.001) had heard about cervical smear. Most of the HK subjects' knowledge of cervical smear came from the mass media (HK=53% Vs BJ=17.4%, p=0.000) while most of the BJ subjects' knowledge came from medical staff (HK=35.3% Vs BJ=52.1%, p=0.02). The average knowledge score on cervical cancer risk factors and screening programme was 6.52 over 11 in HK subjects, which was higher than that of the BJ subjects (5.78 over 11, p=0.001). The majority of subjects in both groups thought that the cost of a cervical smear was not expensive or was appropriate (HK=66.5% Vs BJ=53.5%, p=0.012). They perceived themselves as having moderate or low risk to cervical cancer (HK=96% Vs BJ=72.9% p=0.000). They preferred female personnels to perform cervical smears for them (HK=83.9% Vs BJ=79.9% p=0.368). For the subjects who have had cervical smear before (HK=112, BJ=102), most of the HK subjects had it done in the private sector (54.5%), while all of the BJ subjects (100%) were done by the public sector. More of the HK subjects found the procedure to be painful (HK=15.2% Vs BJ=4.9%, p=0.013) and embarrassing (H= 32.1% Vs BJ=4.9%, p=0.000). For the subjects who did not have a regular cervical smear, the most common reasons in the HK subjects were 'no time' (40%), 'fear of embarrassment' (34.5%) and 'fear of pain' (23.6%). The most common reasons in the BJ subjects were 'no time' (36.1%), 'no need' (29.5%) and 'too expensive' (14.8%).

Conclusion: The regular cervical smear uptake rate was around 60% in both HK and BJ subjects. Insufficient knowledge may cause most of the subjects to under-estimate their risk of cervical cancer. Other reason could be low motivation to have these performed. (no time to perform or feeling no need to perform). While most subjects heard of cervical smear from mass media or medical staff, only half of the HK subjects and most of the BJ subjects did not have a regular family doctor. There is a need for the government and the primary care physicians to provide more patient education on the importance of having regular cervical smears.

Keywords: Chinese, cervical smear, knowledge, attitude, experience.

摘要

目的：比較北京和香港兩地接受宮頸癌篩查女性的特點。

設計：自答問卷。

對象：在香港和北京4所基層醫療診所就診的25-65歲中國女性。

主要測量內容：社會人口學基本特徵；針對宮頸癌篩查專案的知識、態度和自覺風險；宮頸塗片的經驗；未作定期宮頸塗片的原因。

結果：在香港(n=155，56%)和北京(n=144，44%)共收回299份有效問卷。就常規宮頸塗片的接受比率而言，香港女性(63.9%)和北京女性(57.6%)之間無顯著差異(p=0.24)。有較多香港女性聽聞過宮頸塗片(香港=94%；北京=85.4%；p=0.001)。在香港，多數女士對宮頸塗片的認識是來自大眾傳媒(香港=53%；北京=17.4%；p=0.000)；而多數北京女士的知識來自醫務人員(香港35.3%；北京52.1%；p=0.02)。香港女士對宮頸癌形成的風險因素和篩查項目的平均知識水平為6.52/11，高於北京女士(5.78/11；p=0.001)。在這兩組別中，多數人士均認為宮頸塗片的費用低廉或適當(香港66.5%；北京53.5%；p=0.012)。她們自認患宮頸癌的風險為中度或低度(香港96%；北京72.9%；p=0.000)。她們較喜歡由女醫生為其作宮頸塗片(香港83.9%；北京79.9%；p=0.368)。在曾做過宮頸塗片的對象(香港=112北京=102)中，大多數香港女性在私營機構(54.5%)進行，而北京女士則全部都在公立機構(100%)。較多香港女性認為塗片檢查會引起痛楚(香港15.2%；北京 4.9%；p=0.013)和尷尬(香港32.1%；北京4.9%；p=0.000)。在未曾作過定期宮頸塗片的人士中，香港女性最常見的理由為："沒時間"(40%)；"怕尷尬"(34.5%)和"怕痛"(23.6%)。北京女士的最常見理由為"沒時間"(36.1%)，"不需要"(29.5%)和"太貴"(14.8%)。

結論：香港和北京兩地女性的定期宮頸塗片率都約為60%。瞭解不足可能是大多數女士低估宮頸癌風險或不太願意接受檢查的原因(沒時間做或覺得不需要)。她們主要從大眾傳媒或醫務人員處得知宮頸塗片，但半數香港的研究對象和大多數北京對象沒有固定的家庭醫生。政府和基層醫生要對病人提供更多關於定期宮頸塗片的教育。

主要詞彙：華人，宮頸塗片，知識，態度，經驗

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Introduction

Cervical cancer is an important disease both in Hong Kong & China. In Hong Kong, it is the 5th commonest cancer and 8th commonest cancer cause of death in women. The incidence was 439 causing 128 deaths in 2004 by the statistics of the Hospital Authority in Hong Kong.¹ It is also an important disease in China especially in rural China.² The age standardized mortality rate in 1999 was 5.8 per 100,000 and 3.5 per 100,000 in the rural and urban areas of China respectively.³ This compared with 2.9 per 100,000 in Hong Kong in 2004.1 The incidence is particularly high in rural China. A cervical cancer screening study was conducted in Shanxi (rural China) involving 2,000 healthy women. The result was 10.1% cervical smears being identified as abnormal and 0.6% cervical cancer were confirmed by biopsy.⁴

Objective

Previous studies showed the uptake rate of cervical smears in Hong Kong was only 34.9 to 52%,^5-7 compared with 64% in United Kingdom8 and 80- 90% in Finland.9 There was a lack of update data in mainland China. Most of the previous studies about cervical cancer screening targeted a non-Chinese population.^8-10 A few studies concerning factors associated with the Chinese women for not attending regular cervical screening programme were conducted in Hong Kong6,¹¹ and Beijing. The aim of this study was to compare the characteristics of women undertaking cervical cancer screening in Hong Kong and Beijing.

Method

The study was conducted as an anonymous self-administered questionnaire survey in one private general practice clinic in Hong Kong, one government outpatient clinic in Hong Kong, one private clinic and one public outpatient department of a government hospital in Beijing in August 2004. These clinics were selected by convenient sampling. All Chinese women aged 25-64 who attended the above 4 clinics were distributed with the questionnaires during registration. The age range of subjects was designed according to guidelines in Hong Kong.¹² A questionnaire collection box was placed in the waiting area along with cervical cancer screening education pamphlets. Patients were asked to hand in the completed questionnaires before consultation. The collection box was opened only when the data collection period ended. (Figure 1)

The questionnaire (Table 1) was based on the possible related factors from literature review and expert opinions by 2 gynaecologists in Hong Kong (Appendix 1). We used a = 0.20 as the power of study and a = 0.05 (two sided) in the calculation of the sample size by data in a previous study.¹³ The estimated minimal sample size was 62 in each group.

All subjects were categorised as "regular smear group" if they have had smears within the last 3 years and "no regular smear group" if they did not have or if they never had any previous cervical smears. Women who were still virgins or who have had hysterectomies were excluded from this study. Bivariate variables were analysed by Chi square test while the continuous variables were analysed by independent variables T-test. We used Chi square statistics to assess the difference between the two groups in the perceived cost of cervical cancer screening, perceived risk of cervical cancer, age, whether or not they lived with a sexual partner, whether or not they have had children, whether or not they were working, family income, smoking status, whether they had a personal family physician and whether they would share health information with friends or relatives. We used T-test to assess the difference between the total score on knowledge of cervical cancer screening and the total number of children between the two groups.

Results

We distributed 180 questionnaires in Hong Kong and 160 in Beijing respectively over 2 consecutive weeks in July 2004. At the end of the 2 weeks, we collected 167 questionnaires from Hong Kong and 160 questionnaires from Beijing. ¹² Hong Kong subjects and 16 Beijing subjects were excluded because these subjects were still virgins or reported a history of hysterectomy. 63.9% of subjects in Hong Kong and 57.6% of subjects in Beijing reported that they have had regular cervical cancer screenings.

Basic demographic data between subjects in Hong Kong and Beijing

The age distributions between subjects in Hong Kong and Beijing were different. (Table 2) A higher proportion of subjects in Hong Kong were aged 25-34 with a lower proportion aged 45-54 when compared with those in Beijing. There were more active smokers in Hong Kong (12.3%) than in Beijing (3.5%). A much higher proportion of Beijing subjects (92%) reported that they lived with their partner as compared with subjects in Hong Kong (64%). Only 47.1% of subjects in Hong Kong had children compared with 84% of subjects in Beijing. The difference was statistically significant. The difference of job nature among the subjects in Hong Kong and Beijing was statistically significant. There were more clerical staff (HK=36.1% Vs BJ=16.7%) and housewives (HK=31% Vs BJ=7%) in Hong Kong while there were more professionals (HK=16.8% Vs BJ=33.3%) and labour workers (HK=2.6% Vs BJ=18.1%) in Beijing. More subjects in Beijing (50.7%) had higher (tertiary and secondary school or above) educational level than subjects in Hong Kong (32.3%). 50.3% of subjects in Hong Kong had a regular personal family doctor while only 2.8% of subjects in Beijing reported having one. The habit of health information sharing among friends and relatives was similar between Hong Kong and Beijing.

Knowledge, attitude and risk perception on cervical smear screening programme

More HK subjects (94%) had heard about cervical smear than the BJ subjects (85.4%) (p=0.001). (Table 3) HK subjects heard about cervical smear from mass media (53%), medical staff (35.3%) and friends or family (27.8%) as compared with the BJ subjects who heard about cervical smear from medical staff (52.1%), mass media (17.4%) and friends or family (14.6%). The HK subjects scored an average of 6.51 out of 11 questions (95% CI=6.19-6.82), which was significantly higher than the BJ subjects with an average score of 5.78 (95% CI=5.47-6.09) (p=0.001). More BJ subjects perceived that cervical smears were expensive (HK=31.6% Vs BJ=46.5%, p=0.012). More BJ subjects also perceived that they had a high risk of cervical cancer (HK=2.6% Vs BJ=27.1%, p=0.000) while most HK subjects perceived themselves to be at a moderate / low risk of cervical cancer (HK=96% Vs BJ=72.9%). Most subjects from both groups preferred female doctors to perform their cervical smears. (HK=83.9% Vs BJ=79.9%, p=0.368).

Experience of cervical smear

For the women who did a cervical smear before (N=215), 84.6% had regular cervical smears taken and 15.4% did not have cervical smears regularly. (Table 4) Most of the HK subjects had it done in private sector (54.5%) while all BJ subjects had it done in public sector (100%). About half of the subjects (HK=53.6%, BJ=49%) found themselves relaxed during the procedure, while a significant proportion of HK subjects found the procedure painful (HK=15% Vs BJ=4.9%, p=0.013) and embarrassing (HK=32.1% Vs BJ=4.9%, p=0.000). Most of the subjects (HK=94.7% Vs BJ=80.4%) found the attitude of the medical staffs to be positive.

Reasons for not having or planning a regular smear

For the 55 HK subjects who did not have regular cervical smears, the most common reasons were 'no time' (40%), 'fear of embarrassment' (34.5%) and 'fear of pain' (23.6%), followed by 'no need' (21.8%). For the 61 BJ subjects, the most common reasons were 'no time' (36.1%), 'no need'(29.5%), 'too expensive' (14.8%), and 'don't know where to have it done (13.1%). It seems that psychological barrier was a significant issue for the HK subjects while the knowledge and cost barriers were more significant in BJ subjects. Around 50% of HK subjects and 40% of the BJ subjects planned for a cervical smear in the coming 3 months. (Table 5)

Discussions

There is no significant difference between Hong Kong and Beijing subjects in the rate of taking regular cervical smears. On the other hand, a significant proportion (38.9%) of subjects did not have regular cervical smears, which means we should identify these women in our general population and motivate them to join the cancer screening programme.

From Table 2, we learn that the subjects from Hong Kong and Beijing differed significantly in their age group (younger in BJ), smoking status (more smokers in HK), family status (more BJ subjects lived with their partners and had children), occupations (more BJ subjects were working), education level (more higher education in more BJ subjects). The reasons for these may be due to the fact that most of the patients attending the two Beijing clinics were covered by employment health insurance. The second reason may be the cultural difference between the studied subjects. Most Beijing subjects were working, married, lived with a partner and had children. The concept of having a personal family doctor in the Beijing subjects (2.8%) was not popular, while half of the Hong Kong subjects (50.3%) had a personal family doctor.

Although most of our subjects had heard about cervical smear testing, they might not have the correct information or concepts about cervical cancer and its screening programme. This was shown by most subjects getting 3 to 5 wrong answers in the true or false questions section. Our subjects had obtained their cervical smear information from different sources. Most Hong Kong subjects learnt about it from the mass media (53%) while the Beijing subjects' knowledge (52.1%) came from the medical staff. This might be due to large scale promotion of cervical smear screening in Hong Kong. In Beijing, patients usually obtained the relevant information given to them by medical personnels or attending nurses. Therefore the patient education programme in Hong Kong can be delivered through these two channels in future. The opportunistic promotion of cervical smear by our primary health care staffs should be made more effective.

Concerning the experience of having cervical smears, half of the subjects had a positive experience. Most of them perceived our staffs' attitude to be positive. However, there were significantly more HK subjects who felt pain or embarrassment as compared with the BJ subjects. The results correlated with the HK subjects' reasons of not having a regular smear. Some HK subjects stated that the reasons were 'fear of pain or embarrassment', which were statistically insignificant among the BJ subjects. The results indicated that psychological barriers of some patients needed to be addressed before the procedure was performed.

The most common reason for not having a cervical smear was 'no time'. But most of them had an intention to have a smear in the coming next 3 months. Only few subjects thought it was due to 'inconvenient clinic opening time' or 'don't know where it could be done'. This meant therefore that the inconvenience of the health system was not a major barrier to pap smear uptake. It may reflect that patients perceive cervical smear as of low priority. This may further be correlated with the perceived low or moderate risk of cervical cancer seen in this study. It shows the importance of patient education on the risk of cervical cancer and benefit of cervical cancer screening programme.

We used convenient sampling of Hong Kong and Beijing subjects who attended our clinics because of limited resources. The bias could be avoided by population based random sampling in future research. All investigators were female general practitioners. This might explain the relatively high cervical smear uptake rate of our subjects and a strong preference for female doctors. In Beijing, the questionnaires were distributed in a private clinic and an outpatient clinic of the government GOPD. People attending the private clinics in Beijing were considered rich and of a higher social status. This may also cause a selection bias.

Conclusion

The regular cervical smear uptake rate is around 60% in both HK and BJ subjects. Insufficient knowledge may cause most of the subjects to under-estimate their risk of cervical cancer, or have a low motivation to perform regular cervical smears (no time to perform or feeling no need to perform). While most subjects knew about cervical smear testing from the mass media or medical staff, only half of the HK subjects and most of the BJ subjects did not have a personal family doctor. The government and the primary care physicians may need to address this issue by providing more patient education.

Acknowledgements

We would like to thank all our patients who participated in this study and all the medical and nursing staff from the Hospital Authority, Kowloon West Cluster, Department of Family Medicine and Primary Health Care, Cheung Sha Wan Jockey Club Clinic for their cooperation and collaboration. Thanks are due to Miss W M Yip for her help in distributing and collecting the questionnaires in Dr Ip's clinic; Mr C C Lee and Ms Helen Fung for conducting the Protocol Development module and Project Work and Report module of Master of Family Medicine, Chinese University of Hong Kong; Mr Wilson Tam and Professor K K Tsang for advice on the design of the study; Dr H F Tung and Dr Y H Ting (Gynaecologists) for advice on the questionnaire design; Professor A K Y Cheung, Professor A Lee and all other tutors from Department of Family Medicine, Chinese University of Hong Kong for their supervision and advice on this study. Last but not least, we would like to especially thank Professor Cui Shuqi, Professor Guo Aimin at the Public Health and Family Medicine School of Capital University of Medical Sciences and Professor Lu Zhaofeng, President of Capital University of Medical Sciences, for their valuable advice. This study was approved by the Ethical Committee, Hospital Authority, Kowloon West Cluster, Hong Kong.

Key messages

1. The uptake rate of cervical smear was around 60%.
2. Most of the Hong Kong subjects learnt about cervical smear from the mass media while the Beijing subjects learnt about it from the medical staff.
3. The Beijing subjects had lower score on knowledge of cervical cancer than the Hong Kong subjects.
4. The Hong Kong subjects had more negative experience on previous cervical smear.
5. The most common reasons of not have cervical smear was 'no time', 'fear of pain or embarrassment'.

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References