INTRODUCTION:

About 70-80% of cervical cancers in our countries present themselves at an advanced stage¹. CC is a preventable disease. The 96900 annual cases and more than 60000 lethal cases could have been greatly reduced if the symptoms were known or if patients had effective preventive programs as in developed countries. India is deeply hit by this disease, second most cancer in India ^2,46,47,48. In India, the prevalence of this disease is about 22.4% according to some studies done on the field³. The incriminating agent is the human papilloma virus (HPV) ⁴, which is found in 99.7% of cases of cervical cancer⁵. This agent is sexually transmissible⁶.

There exist about 100 species⁷, which are not all pathogenic. Specie 16 and 18 represent 2/3 of pathological cases⁸. Some identified risk factors for CC are hygienic conditions, onset of sexual activities at a very young age, multiple sexual partners, polygamy, person leaving with HIV infection, infection with HPV, low socioeconomic status, multiple deliveries, recurrent STDs. Although risk factors are universal, they do vary according to geographical locations and sociocultural peculiarities⁹. How do some of these risk factors affect the development of CC?

HPV: is at the epicenter of CC. This virus is detected in 99.7% from all premalignant to invasive cancer of the cervix of the uterus^10,11,12. It is also found in perineal, oral, pharyngeal, and esophageal lesions¹³. There are 100 species, but not all are pathological. Species 8, 11, 16, 18, 31, 33, 45, 52, and 58 are responsible for precancerous lesions and invasive CC¹⁴. HPV acts through the help of its oncoproteins E6 and E7. These oncoproteins have a deleterious effect on the major tumor suppressors; retinoblastoma and P53. Furthermore, they get integrated into the host cell's DNA and distort the normal functioning of the infected cells. This brings about the malfunctioning of the sense of contact, cellular control, immune response, and apoptosis¹⁵

HIV: women younger than 25 years generally clear the cervical HPV infection because of their strong immune system¹⁶. Women with HIV have higher odds of being infected with oncogenic HPV¹⁷ Immune suppression in presence of HPV will lead to permanent infection of the cervix of the uterus by the HPV, with time this could lead to the development of cervical dysplasia¹⁸. A good immune system will combat cancer cells as well as slowing down their growth and development¹⁹

Chlamydia trachomatis: is a sexually transmitted disease that can cause inflammation of the genital tract, leading to infertility. In general, this infection is asymptomatic ²⁰. Its DNA has been found in about 40% of cervical invasive cancers²¹. The presence of chlamydia alongside the chronic inflammation leading to dysplasia makes it more difficult to clear off the HPV²³. this brings along a concentration of E6 and E7 oncogenes with their clinical expression.

Furthermore, the presence of antibodies directed against chlamydia carries the odds of 1.8 being associated with squamous epithelial cancer²³. the higher the antibodies, the higher the odds in women less than 55 years old.

Smoking:

Smoking is considered as one of the most important cofactors in the genesis of CC. Nicotine has been detected in the cervical mucous of women having CC ³⁶. Women who smoke have twice the chance of developing CC. The risk is proportional to the number of cigarettes smoked^24,25. The chances of developing CC are halved after 10 years in women who stopped smoking. Nicotine and byproducts do not only alter the DNA but also induce a local immune depression in cervical squamous cells, making it possible for HPV to strive²⁵.

Early onset of sexual activities: It is thought that cervix is immature mostly below 18 years. The local immunity is wanting, so the cervix cannot defend itself. HPV can settle on such cervixes on chronic mode²⁶.

Multiple sexual partners: HPV is a sexually transmissible disease. The risk of infection is proportionate to the number of sexual partners²⁷. About 75% of women will be exposed to HPV during their sexual life²⁷

Multiple parities:

Multiple pregnancies are synonymous with repeated cervical trauma. This renders the cervix more vulnerable. Multiple sexual encounters spread over long periods could be a risk factor depending on the individual's social behavior and immune status²⁸

Low economic social status: Capacitating the woman financially will go a long way towards facilitating independence in health-related decisions^22,29,30. Women with a low social status fight for daily survival and will accord less attention to health issues, mostly in the domain of prevention. Even if they are aware of some health problems, they will hardly go to a hospital because of lack of money. At the level of the country, the situation is not better. Screening exercises are rare because of a lack of resources and manpower. The skeletal health system looks overwhelmed. Efficient long term follows up of patients, referral and counter referral systems, traceability, cohort follow up of patients are all wanting³⁰

Level of education: Awareness and knowledge about CC rise according to the level of education. Some people with little or no education are even ignorant of the existence of CC. With a high level of education, many women are aware of symptoms of the disease and go out in search of preventive measures and rational treatment ^30,31. The objective of our study is to describe knowledge level and risk factors of CC in women in towns of Pune division Maharashtra.

MATERIALS AND METHODS:

Study design, sample population, and strategy.

This was a community-based cross-sectional study carried out from the 20th to 30th of December 2020, in different region: Satara, Pune, and Sangli in the Maharashtra. Satara and its environment have a population of 3,003,741 inhabitants, Pune has a population of 9,429,408 and Sangli has a mainly farming and trading population of 2,822,143⁴⁵.

Sampling procedure:

Women aged from 15 to 62 years were recruited for the study. Peer educators thoroughly explained the questionnaires and procedures to respondents, as well as assuring them of anonymity and confidentiality. Questionnaires were then administered to those who consented. Pregnant women and those with a history of total hysterectomy were excluded from the study.

Sample size determination:

The sample size was calculated using the CDC-Epi InfoTM 7.2.3.1 StatCalc software, with the following characteristics: an estimated population size for Pune Division (Satara, Sangli, Pune region) of 15000000 inhabitants ³⁹, expected frequency of persons living with cervical cancer in Maharashtra of 22.86%⁴⁰, accepted error margin of 5%, design effect of 1.0 and one clusters. Thus, the CDC-Epi InfoTM 7.2.3.1 StatCalc estimated minimum sample size was 183.

Research instrument and Data Collection:

The data instrument (paper-based questionnaire) was adapted from a related study²⁴. The questionnaire contained sections to capture demographic characteristics, awareness, and knowledge of cervical cancer. Trained peer-educators/nurses administered the questionnaires. A pilot session of the questionnaire was done before the survey to ensure that respondents were able to understand it and that questions were interpreted as intended.

Knowledge of cervical cancer was assessed on six questions (Table 2); five of which were True/False/I don't know and one Yes/No question. A negative response was assigned a score of '1', and a positive response '0' for the Yes/No question. All of the True/ False questions were considered true. Responses for these questions were coded as '1' for a correct ("True") and '0' for an incorrect response ("False/I don't know"). A composite score was derived for each respondent. Composite scores of 5 – 6 were considered a highly knowledge level, 3 – 4 were considered a medium level knowledge. Scores of 1-2 were considered to indicate a low knowledge level.

Study variables:

The dependent variable in this study was the knowledge level score, determined as describe above. Independent variables were respondents' general characteristics.

Statistical Analysis:

Data was captured into Microsoft Excel Office 2018 (Microsoft Inc) and exported to CDC-Epi InfoTM 7.2.3.1 (CDC-Epi InfoTM, USA) for statistical analysis. Categorical variables are presented as frequency tables and the association between knowledge of cervical cancer (none/low/medium) and demographic characteristics were assessed using bivariate analysis, and multivariate logistic regression analyses. Odds ratios (O.R) and Chi-square (χ2) tests were used to compare participants' characteristics with knowledge of cervical cancer. P-values ≤ 0.05 were considered significant.

Limitations and Strengths of the Study:

The data that was acquired from the questionnaire completely depended on self-reported accounts of respondents. However, questionnaires were pre-tested and administered by trained peer-educators or nurses.

RESULTS:

A total of 250 consecutively enrolled participants were included in this analysis; their general characteristics are presented in Table 1.

Table 1: General characteristics of study participants

Characteristic	Subclass	Frequency (%)
Age groups (Years)	15 – 20	55 (22.0)
	21 – 30	62 (24.8)
	31 – 40	60 (24.0)
	41 – 50	43 (17.2)
	> 50	30 (12.0)
Age of first sex (Years)	15 – 20	145 (58.0)
	21 – 25	68 (27.2)
	26 – 30	26 (10.4)
	31 – 35	9 (3.6)
	36 – 40	2 (0.8)
Education	No Formal Education	25 (10.0)
	Primary	52 (20.8)
	Secondary	78 (31.2)
	Tertiary	95 (38.0)
Marital status	Single	97 (38.8)
	Married	130 (52.0)
	Divorcee	5 (2.0)
	Widow	18 (7.2)
Residence	Satara	82 (32.8)
	Pune	85 (34.0)
	Sangli	83 (33.2)

The ages of respondents ranged from 15 – 62 years with the overall mean (x ± SD) age being 33.2±12.7 years. The largest age group of study participants were 21 – 30 years old, with 24.8%of respondents in this group. The next most populous group was the 31–40 years age group at 24%, and the least being the more than 50 years age group 12%. A little more than one-third 95(38%) of the respondents had attended tertiary education, followed by 78(31.2%) with secondary education, 52(20.8%) with primary and then 25(10%) with no formal education. 52% of our sample population was married, followed by 38.8 % made of single women, then 7.2 and 0.2%, respectively for widows and divorcees.

Knowledge and risks of cervical cancer of the 250 participants, only 4(1.6%) had previously taken the HPV vaccine. Participant's knowledge of cervical cancer is presented in Table 2.

54 and 28.8% making a total of 82.8% of our sample population cannot establish the link between HPV and cervical CC. Just 29.9% of our sample think that CC is preventable. 54.8% do not know that treatment of precancerous lesions can prevent CC. Just 28% are aware that there is a test to detect HPV. 59.6 % do not know of the existence of any vaccine against CC. Just 36.6% of our sample study are aware that infection with HPV could lead to CC. In our sample, nobody was highly knowledgeable in CC. The percentages were 26.4, 46.4, and 22.7 respectively for no measurable, low, and medium knowledge levels

Table 2: Knowledge of cervical cancer

Question on knowledge of cervical cancer	True	False	I don’t know
Infection with HPV increases risk of cervical cancer	43 (17.2)	72 (28.8)	135 (54.0)
Cervical cancer is preventable (Y/N)	74 (29.6)	143 (57.2)	33 (13.2)
Treatment for precancerous lesion can help prevent cervical cancer	113 (45.2)	36 (14.4)	101 (40.4)
Is there a test to check if someone is infected with HPV	70 (28.0)	101 (40.4)	79 (31.6)
Is there a vaccine to prevent cervical cancer	101 (40.4)	88 (35.2)	61 (24.4)
All women infected with HPV get cervical cancer	91 (36.4)	11 (4.4)	148 (59.2)
Graded knowledge of cervical cancer		Frequency	%
0		66	26.4
1		44	17.6
2		72	28.8
3		48	19.2
4		20	8.0
No measurable knowledge		66	26.4
Low knowledge level		116	46.4
Medium knowledge level		68	22.7

Cervical Cancer Risk/Protective Factors are presented in Table 3.

Table 3: Risk of cervical cancer

Risk of cervical cancer	Subclass	Frequency	%
Prior CC screening		43/227	17.2
Duration of previous screening (years)	0 – 3	16/207	37.2
	4 – 5	10/207	23.3
	6 – 10	12/207	27.9
	> 10	05/207	11.6
Prior treatment of CC		04/244	1.6
History of genital warts		44/250	17.6
Age of first sex	15 – 20	145/250	58.0
	21 – 25	68/250	27.2
	26 – 30	26/250	10.4
	31 – 35	09/250	3.6
	36 – 40	02/250	0.8
Number of sexual partners in the last 5 years	0 – 3	196/243	80.7
	4 – 6	46/243	18.9
	7 – 10	01/243	0.4
Is your husband having other wives		03/115	2.6
Is your husband having other sexual partners		73/240	30.4
Have you had a vaccine for HPV?		04/242	1.7
Are you HIV positive		10/231	4.3
Have you had any STI in the last one year		26/227	11.5
Are you on oral contraceptives for family planning?		34/249	13.7

Just 17.2% of our studied population had had a previous CC screening, and only 37.2 of this group had screening 0-3 years ago. 1.6% had some prior treatment for CC. 17,6% have a history of genital warts. 58% of our sample had their 1st sexual intercourse between 15-20 years of age. About the number of sexual partners for the last 5 years, 80.7% had 0-3 partners, 18.9 had between 4-6 sexual partners, and 0.4% had 7-10 sexual partners. 2.6 % of our studied population come from a polygamous marriage. 30.4% of women interrogated affirm that their husbands have extra conjugal affairs with some other women. Just 1.7 of our sample had received an HPV vaccine. 4.3% of our sample is HIV positive. And 11.5 % of women interrogated confirm to have had at least one episode of a sexually transmitted disease for the past year. 13.7% are using a contraceptive method.

Association between knowledge of Cervical Cancer and patients' characteristics

Age and educational status had a significant association (p < 0.05) with knowledge of CC (Table 4), in both bivariate analysis and multinomial regression analysis.

Table 4: Associations between respondents’ characteristics and knowledge of cervical cancer

DV →		Knowledge of cervical cancer
Variable ↓	Subclass	No (%)	Yes (%)	Total (%)	p-value	O.R (95% C.I)
Age groups (Years)	15 – 20	2 (3.0)	53 (28.8)	55 (22.0)	9.01x10^-4*	0.0 (0.0 – 0.3)
	21 – 30	2 (3.0)	60 (32.6)	62 (24.8)	2.45x10^-4*	0.0 (0.0 – 0.2)
	31 – 40	28 (42.4)	32 (17.4	60 (24.0)	0.56	1.4 (0.5 – 4.0) †
	41 – 50	24 (36.4)	19 (10.3)	43 (17.2)	0.13	2.4 (0.8 – 7.2) †
	> 50	10 (15.2)	20 (10.9)	30 (12.0)	Ref	1.0
Education	NFE	9 (13.6)	16 (8.7)	25 (10.0)	0.27	2.3 (0.5 – 10.5) †
	Primary	18 (27.3)	34 (18.5)	52 (20.8)	0.05	2.7 (1.0 – 7.3) †
	Secondary	6 (9.1)	72 (39.1)	78 (31.2)	3.99x10^-3*	0.2 (0.1 – 0.6)
	Tertiary	33 (50.0)	62 (33.7)	95 (38.0)	Ref	1.0
Marital status	Single	17 (25.8)	80 (43.5)	97 (38.8)	0.69	0.7 (0.1 – 3.5)
	Married	39 (59.1)	91 (49.5)	130 (52.0)	0.26	2.5 (0.5 – 11.9) †
	Divorced	4 (6.1)	1 (0.5)	5 (2.0)	0.22	5.2 (0.4 – 72.1) †
	Widowed	6 (9.1)	12 (6.5)	18 (7.2)	Ref	1.0
Residence	Satara	24 (36.4)	58 (31.5)	82 (32.8)	0.93	1.0 (0.4 – 2.4)
	Pune	18 (27.3)	67 (36.4)	85 (34.0)	0.57	0.8 (0.3 – 2.0)
	Sangli	24 (36.4)	59 (32.1)	83 (33.2)	Ref	1.0
	Total	66	184	250

*p-values with statistical significance, NFE; No formal education

The association between the respondents' characteristics and CC, is statistically significant for the age groups 15-20 and 21-30. The odds of not being knowledgeable about CC are increased by 2.3 and 2.7 for persons with no formal education and primary level of education respectively. On the other hand, it is statistically significant for secondary school education. Tertiary education was used as the dependent characteristic. The odds of knowing CC are increased by 2.5 and 5.2 for married women and divorcees.

DISCUSSION:

Risk factors:

Number of sexual partners

0.4 and 18.9% of our study population have had respectively 7-10 and 4-6 sexual partners for the past 5 years. CC is a sexually transmissible disease, and higher the number of partners increase the risk of being infected ^12,32. 75% of sexually active women may come in contact during their active life with the HPV¹². In this same trend, 2.6% of our respondents have contracted a polygamous marriage and 30.4% report that their husbands have extramarital affairs with other women ^33,34. The male partner can carry the HPV from an infected partner to a non-infected female partner³⁵.

Age at 1st sex: 58% of our sample population had their 1st sexual intercourse between 15- 20 years. Authors are unanimous, at this tender age ≤ 18 year of age, the cervix is immature and unable to defend itself adequately against HPV, making this age group vulnerable to HPV chronic infection^36,37.

HIV infection: HIV infection is a risk factor for CC^30,35. 4.3% of our sample population is HIV +. In addition to this, 11.5% of this same population affirms having had at least one episode of STI for the last year. STIs are also risk factors for HPV infections³⁷.

History of HPV-related infection: genital warts were found in 17,6% of our sample population. About 100 species of HPV do exist and species 6,11 mostly account for genital warts^14,69. Lifestyle enhancement: some behavioral patterns deeply anchored in our populations are regarded as "risky".

Knowledge Education:

Education is pivotal in the acquisition of knowledge, all researchers converge view on this^34,35,36. The more a woman is literate, the sharper is her sense of judgment. Her mindset is tilted towards rational thinking. Formal education exposes one to new concepts. Knowledge could be acquired formerly and permits the learner to understand the intricacies of the disease⁴². In our study, the bulk of our sample, 72.8% was rather not at all knowledgeable or lowly knowledgeable. Just 22.7% were averagely knowledgeable.

Age groups.

The age groups 15-20 and 21-30 are statistically significant as far as knowledge is concerned. This is owed to the demographic structure of Maharashtra’s population, with an essentially young population^37,43. It is also at this age that secondary and tertiary levels of education are attained. The reason may be the youthful pattern of Maharashtra 's population and schools.

MARITAL STATUS:

Some sub-components in the marital status seem to be favorable for the acquisition of knowledge about CC. 2.5 and 5.2% are the increased chances in married and divorcees to be more knowledgeable in matters patterning to CC. For the former, the reason may be that they are engaged in a stable relationship, so more attention is accorded to health issues. For the latter, they may be aware of the fact that they belong to a risk group, and they do their best to acquire knowledge regarding some health issues⁴⁴.

CONCLUSION:

Although preventable, CC continues to constitute a real burden on the fragile health structures of developing countries. First sexual intercourse at a very young age, multiple sexual partners, the male sexual factor, people living with HIV, history of genital warts and STDs, have been identified as possible risk factors for CC. Some personal decisions as not attending CC screening and none acceptance of vaccination against HPV are regarded as deleterious for the fight against CC. Acquisition of knowledge is a function of the level of education. The higher one is learned, the better the knowledge on CC. In this study, young age is also a contributory factor for the acquisition of knowledge.

REFERENCE:

1. Zohre Momenimovahed and Hamid Salehiniya. Incidence, mortality, and risk factors of cervical cancer in the world. The Vietnamese Journal of Biomedicine Vol 4 No12(2017) /1795-1811.

2. W. A. Leyden, M. M. Manos, A. M. Geiger, S. Weinmann, J. Mouchawar, K. Bischoff, S. H. Taplin. Cervical cancer in women with comprehensive health care access: Attributable factors in the screening process. Journal of the National Cancer Institute. 2005; 97(9): 675-683.

3. C. Jegatha, V. Hemavathy, KR. Vasanthakohila. Effectiveness of Structured Teaching Programme on Knowledge of Women Regarding Cancer Cervix. Research J. Pharm. and Tech. 8(3) : Mar., 2015; Page 335-338.

4. F. X. Bosch, N. Muñoz. The viral etiology of cervical cancer. Virus Research. 2002; 89(2): 183-190.

5. Dwira S., Fadhillah M. R., Fadilah F., Azizah N. N, Putrianingsih R., Kusmardi K.. Cytotoxic Activity of Ethanol and Ethyl Acetate Extract of Kenikir (Cosmos caudatus) against Cervical Cancer Cell Line (HELA). Research J. Pharm. and Tech. 2019; 12(3): 1225-1229.

6. E. J. Crosbie, M. H. Einstein, S. Franceschi, H. C. Kitchener. Human papillomavirus and cervical cancer. Lancet. 2013; 382(9895): 889-899.

7. Bhagwan Gamaji Ambhore , Kavita Ambhore. Knowledge, Attitude and Practice Study of Teenage Mothers about Contraceptives. Research J. Pharmacology and Pharmacodynamics. 2013; 5(3): 162-163.

8. A. Monie, C.-F. Hung, R. Roden, T. C. Wu. CervarixTM: A vaccine for the prevention of HPV 16, 18-associated cervical cancer. Biologics. 2008; 2: 107.

9. Nishandhini Marimuthu, Viswanathan T, Mahendran Radha, Jeyabaskar Suganya. Computational Screening of the Phytocompounds from the Plant Ballota nigra Linn against the Human Papillomavirus (HPV) E6. Research J. Pharm. and Tech 2017; 10(9):3095-3097.

10. E. Roura, X. Castellsagué, M. Pawlita, N. Travier, T. Waterboer, N. Margall, I. T. Gram. Smoking as a major risk factor for cervical cancer and pre-cancer: Results from the EPIC cohort. International Journal of Cancer. 2014; 135(2): 453-466.

11. S. Vaccarella, J. Lortet-Tieulent, M. Plummer, S. Franceschi, F. Bray. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. European Journal of Cancer. 2013; 49(15): 3262-3273.

12. P. Mangala Gowri, Beautily, S. Santhalakshmi, M. Nandhini, Tamizharasan M. Assess the factors affecting the non utilization of Cervical Cancer screening services among women attending in nemam Primary Health Center. Research J. Pharm. and Tech 2018; 11(7): 3128-3130.

13. Amulya Vijay, V. P. Sona, A. Radha, P. Vinayaga Moorthi. A Review on Advancement Perspectives in Cervical Cancer. Research J. Pharm. and Tech 2017; 10(12): 4410-4414.

14. Gallioway DA. Is vaccination against HPV a possibility? Lancet 1998; 351: 22-4.

15. Jadhav, Kishan L., Priyanka R. Kapare, Divya V. Khairmode, Chaitali H. Keskar, and Akash S. Mali. Genetic Insights of Cholesterol and Atherosclerosis; Complex Biology. Journal of Diseases 5, no. 1 (2018): 10-23.

16. .Juneja A, Sehgal A, Mitra AB, Pandey A. A Survey on Risk Factors Associated with Cervical Cancer. Indian Cancer Society Indian Journal of Cancer, Vol. 40, No. 1, (January - March 2003).

17. Krishnaveni K, Rosmi Jose, Sumitha SK, Teena Johny, Shanmuga Sundaram R, Sambathkumar R. A Study on Socio Demographic and Associated Risk Factors for Cancer Patients in Private Cancer Hospital, Bangalore, India. Research J. Pharm. and Tech 2018; 11(2):677-680.

18. Mali, Akash, Bodake Swapnil, Jadhav Pooja, Mali Dwaraka, and Jurgelevičius Vaclovas. "Past, present and future about Ebola virus diseases: An updated review." Journal of Pharmacy Practice and Community Medicine 2, no. 2 (2016).

19. Z. Z. Mbulawa, D. J. Marais, L. F. Johnson, A. Boulle, D. Coetzee, A.-L. Williamson. Influence of human immunodeficiency virus and CD4 count on the prevalence of human papillomavirus in heterosexual couples. The Journal of General Virology. 2010; 91(12): 3023-3031

20. L. Pantanowitz, P. Michelow. Review of human immunodeficiency virus (HIV) and squamous lesions of the uterine cervix. Diagnostic Cytopathology. 2011; 39(1): 65-72.

21. P. Koskela, T. Anttila, T. Bjørge, A. Brunsvig, J. Dillner, M. Hakama, P. Lenner. Chlamydia trachomatis infection as a risk factor for invasive cervical cancer. International Journal of Cancer. 2000; 85(1): 35-39

22. J.S. Smith, C. Bosetti, N. Muñoz, R. Herrero, F.X. Bosch, J. Eluf-Neto, R.W. Peeling. Chlamydia trachomatis and invasive cervical cancer: Apooled analysis of the IARC multicentric case-control study. International Journal of Cancer. 2004; 111(3): 431-439.

23. Shatha Mahmood Niazi. Assessment the Risk Factors of Twin Pregnancy in Baghdad Iraq. Research J. Pharm. and Tech. 2019; 12(7):3251-3254.

24. M. Plummer, C. de Martel, J. Vignat, J. Ferlay, F. Bray, S. Franceschi. Global burden of cancers attributable to infections in 2012: A synthetic analysis. The Lancet. Global Health. 2016; 4(9): e609-e616.

25. Myat Moe Thwe Aung, San San Oo, Azmi Bin Hassan, Safiya Binti Amaran, Megat Mustaqim Bin Megat Iskandar, Aniza Binti Abd Aziz, Rahmah Binti Mohd Amin, Tengku Mohammad Ariff Bin Raja Hussin, Vidya Bhagat. Prevalence Study on Tobacco Smoking and Related Factors of Among Residents of a Suburb Kuala Terengganu, Malaysia. Research J. Pharm. and Tech. 2019; 12(5):2430-2438.

26. Aayarekar, Pradnya, Komal Lokhande, Farida Shaikh, Priyanka Kapare, Kishan Jadhav, Audrius Maruška, and Akash Shivling Mali. "Zika virus disease." International journal of advanced community medicine. Bangladesh.2018, vol. 1,2 (2018).

27. K. Louie, S. De Sanjose, M. Diaz, X. Castellsague, R. Herrero, C. Meijer, F. Bosch. Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries. British Journal of Cancer. 2009; 100(7): 1191-1197.

28. Martin CE. Marital and coital factors in cervical cancer. Am J Pub Hlth 1967; 57: 803-14.

29. Rotkin ID. Epidemiology of cancer of cervix. Sexual characteristics of cervical cancer population. Am J Pub Hlth 1967; 57: 815-29.

30. Parazzini F, La Vecchia, Negri E, Lecchet G, Fdele L. Reproductive factors and risk of invasive and intraepithelial cervical neoplasms. Br J Cancer 1989; 59: 800-9.

31. Brinton LA, Famman R, Reeves WC, De Brinton RC, Gaaitan E, Tenorio F. Risk factors for cervical cancer by Histology. Gynecol Oncol 1993; 51:301-6.

32. Geetha P, Shanmugasundaram P. A Prospective Observational Study on assessment of risk factor associated with diabetic retinopathy in patients diagnosed with type 2 Diabetes Mellitus in south Indian population. Research J. Pharm. and Tech 2019; 12(2):595-599.

33. Brown S, Vessey M, Harris R. Social class, sexual habits and cancer cervix. Comm Med 1984; 6:281-6.

34. A. Hildesheim, R. Herrero, P. E. Castle, S. Wacholder, M. Bratti, M. Sherman, A. C. Rodríguez. HPV co-factors related to the development of cervical cancer: Results from a population-based study in Costa Rica. British Journal of Cancer. 2001; 84(9): 1219-1226.

35. J. Kim, B. K. Kim, C. H. Lee, S. S. Seo, S.-Y. Park, J.-W. Roh. Human papillomavirus genotypes and cofactors causing cervical intraepithelial neoplasia and cervical cancer in Korean women. International Journal of Gynecological Cancer. 2012; 22: 1570-1576.

36. N. Muñoz, S. Franceschi, C. Bosetti, V. Moreno, R. Herrero, J. S. Smith, F. X. Bosch. Role of parity and human papillomavirus in cervical cancer: The IARC multicentric case-control study. Lancet. 2002; 359(9312): 1093-1101.

37. Sharma HK, Prashar S. Impact of socioeconomic risk factors on carcinoma cervix: Hospital based pap smear screening of 2 years in Bihar. IP Archives of Cytology and Histopathology Research. 2018; 3: 39-42.

38. Muthulakshmi, Ramya. R. A Study to assess the knowledge of Breast Cancer and awareness of Mammography among women (30-50) in Saveetha Medical College and Hospital. Research J. Pharm. and Tech 2018; 11(10): 4219-4221.

39. Kaku M, Mathew A, Rajan B. Impact of socio-economic factors in delayed reporting and late-stage presentation among patients with cervix cancer in a major cancer hospital in South India. Asian Pac J Cancer Prev. 2008; 9: 589-94.

40. Belglaiaa E, Souho T, Badaoui L, Segondy M, Pretet J-L, Guenat D, et al. Awareness of cervical cancer among women attending an HIV treatment center: A cross-sectional study from Morocco. BMJ Open. 2018;8: e020343

41. Thulaseedharan JV, Malila N, Hakama M, 28. Esmy PO, Cheriyan M, Swaminathan R, et al. Socio demographic and reproductive risk factors for cervical cancer – a large prospective cohort study from Rural India. Asian Pac J Cancer Prev. 2012;13(6):2991-5.

42. Sunita. Application of Knowledge Management in Library and Information Centre. Research J. Humanities and Social Sciences. 4(4): October-December, 2013, 519-522.

43. Khushboo Brar, Tarundeep Kaur, P. Vadivukarrasi Ramanadin. Knowledge regarding Poly Cystic Ovarian Syndrome (PCOS) among the Teenage Girls. Int. J. Nur. Edu. and Research.2016; 4(2):136-140.

44. V. Indra. A study to assess the Health Seeking Behavior of Women towards Cervical cancer screening among Women in Selected Areas of Puducherry. Int. J. Nur. Edu. and Research 3(4): Oct.-Dec., 2015; Page 354-362.

45. List of districts of Maharashtra (census2011.co.in)

46. Cancer Statistics - India Against Cancer (cancerindia.org.in)

47. Cervical cancer | National Health Portal Of India (nhp.gov.in)

48. What Is Cervical Cancer? | Types of Cervical Cancer

Received on 19.05.2021 Modified on 28.11.2021

Asian J. Res. Pharm. Sci. 2022; 12(2):91-96.

DOI: 10.52711/2231-5659.2022.00015