| Abstract|| |
Background: Absence or low uptake of Pap smear is probably the main barrier for high incidence of cervical cancer. Aim: To assess the knowledge, practice, attitude, main barriers and motivating factors of Pap smear among Omani women. Methods: Cross-secal survey in a tertiary referral hospital. The participants were divided into three groups: the patients who attended Outpatient Gynecology Department in Sultan Qaboos University Hospital (SQUH), Oman, the female staff from SQUH, College of Medicine and Health Science and College of Nursing at Sultan Qaboos University (SQU) and the graduating female students at SQU. Results: There were 204 patients, 133 staff, and 157 students. The knowledge of Pap smear among patients, staff and students was as follows: 56.9%, 56.4% and 23.6%, respectively. Those who had an adequate knowledge, 36.8% patients, 23.3% staff and 0.0% students performed Pap smear. Those who performed Pap smear, 32.4% of patients were reminded by their health professionals and 23.3% of staff understood the importance of Pap smear. The common barrier that prevents the uptake of Pap smear among the three groups was their belief that they have a healthy lifestyle. All the groups (70 – 96%) believed that Pap smear can lead to more successful prevention and treatment for cervical cancer. Conclusions: The findings of this study show poor knowledge and performance of Pap smear and good attitude towards Pap smear. More public health education is required to inform the community about the importance of Pap smear as well as to strengthen the curriculum taught in undergraduate university.
Keywords: Attitude, cervical cancer, knowledge, Pap smear, practice
|How to cite this article:|
Alwahaibi NY, Alramadhani NM, Alzaabi AM, Alsalami WA. Knowledge, attitude and practice of Pap smear among Omani women. Ann Trop Med Public Health 2017;10:396-403
|How to cite this URL:|
Alwahaibi NY, Alramadhani NM, Alzaabi AM, Alsalami WA. Knowledge, attitude and practice of Pap smear among Omani women. Ann Trop Med Public Health [serial online] 2017 [cited 2020 Feb 26];10:396-403. Available from: http://www.atmph.org/text.asp?2017/10/2/396/208731
| Introduction|| |
Pap smear More Details test is considered to be one of the most effective cervical screening programmes worldwide. In developed countries, where Pap test is frequently performed, the risk of getting cervical cancer is low. It is known that the progression of cervical cancer is relatively slow, passing through many stages of precancerous intraepithelial lesions before reaching to its aggressive form. Thus, it has a great potential for early prevention and cure. This characteristic of the disease, along with the relative simplicity of Pap test, has allowed an early detection of the disease in its earliest stage. In addition, immunization against human papilloma virus (HPV), which is the main causative agent for cervical cancer, has further reduced the risk of cervical cancer.
Lack of knowledge about cervical cancer and absence or low uptake of Pap smear are probably the main barriers for high incidence of cervical cancer. Cervical cancer remains one of the top most common cancers among females worldwide. It is classified as the fourth most common cancer among women worldwide and the second commonest in developing countries with an estimation of 530 000 new cases in 2012 and more than 270 000 deaths every year. In Oman, cervical cancer is classified as the third most common cancer among women. This is the first study in Oman to estimate the level of knowledge, practice and attitude of Pap smear among Omani women. Therefore, this study aimed to assess the knowledge, practice, attitude, main barriers, and motivating factors of Pap smear among Omani women.
| Methods|| |
This is a cross-secal survey that was carried out from August 2015 to April 2016. The participants were recruited and divided into three categories. The first group composed of Omani women from any age group who attended Outpatient Gynecology Department in Sultan Qaboos University Hospital (SQUH), Oman. The second group contained Omani female staff from SQUH, College of Medicine and Health Science and College of Nursing at Sultan Qaboos University (SQU). The participants of third group were graduating Omani female students at SQU.
This study was ethically approved by the Medical Research Committee and Ethics Committee from the College of Medicine and Health Sciences, (SQU), Oman (MREC # 1139). A written consent was obtained. All the participants were ensured about the confidentiality, they were informed that their participation is voluntary and they have full right to withdraw from the study at any time without reasons.
The questionnaire was designed based on critical literature review on Pap smear., It was divided mainly into three main parts: the first included the socio-demographic profile of the participants such as age, marital status, educational levels. The second part consisted of number of questions that assess the participant's knowledge regarding Pap smear such as the frequency, importance of the test, the usual follow up after an abnormal Pap results. The third part dealt with the practice and attitude of Pap smear test and its utilization, this part asked women whether they have ever performed a Pap smear, motivating factors that encouraged them to perform the smear test and themain barriers that prevent them from performing the test.
Data collection started through an interview-based questionnaire for the first category of participants, the gynecology outpatients, to assure their complete understanding of the asked questions and to ensure the validity of received responses. However, self-administered online copy of the questionnaire was prepared for participants of SQU staff and students as they had no time to interview them.
An absolute and relative frequencies (N and %) were obtained for the distribution of the participants by their socio-demographic characteristic, their Pap smear knowledge, attitude, and practice. Pearson Chi-square test was used to determine the differences in the distribution of the above selected variables. It considered significant if p value < 0.05. A cumulative Pap smear knowledge score was calculated for each participant based on their response. The study responses were divided; each correct answer got a score of one, whereas incorrect answer, including “I don't Know” got a score of zero. Then, Pap smear knowledge was categorized as “Adequate” if there were ≥ 6 correct responses (approximately two-thirds) of the nine knowledge questions.
| Results|| |
A total of 494 participated in this study. There were 204 gynecological outpatients, 133 SQU and SQUH female staff, and 157 SQU female students from all the nine colleges (Agricultural and Marine Sciences, Arts and Social Sciences, Economics and Political Science, Science, Nursing, Education, Law, Engineering and Medicine and Health Sciences). Their socio-demographic characteristics, knowledge, attitude, practice, barriers and motivating factors on Pap smear were evaluated.
Out of the total outpatients, 97% were married. The educational level of 44.6% of them was non-medical university degree. Regarding SQU medical staff, 58% were married and their educational levels were above secondary school with the highest percent with medical university degree (36.8%). Regarding the graduating students, 92% were single [Table 1].
|Table 1: Socio-demographic characteristics of SQUH gynecological outpatients, SQU staff and students|
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The knowledge of Pap smear among outpatients 56.9%, staff 56.4% and students 24%. There were no significant differences in the distributions of the three categories (SQUH outpatients, SQU medical staff and students) by their marital status (p> 0.05) [Table 2].
|Table 2: Association between marital status and the level of knowledge of Pap smear among SQUH gynecological outpatients, SQU staff and students|
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Assessing the presence of any correlation between the knowledge of Pap smear among the outpatients and the staff and their educational level revealed no significant differences at p value > 0.05. However, no p value could be obtained for the students since all of them were undergraduates (for example their educational level could not be categorized). In outpatients, it was found that the adequate knowledge of Pap smear were high among undergraduate (66.7%), followed by equal percentage among medical and non-medical university degree (61.5%). In the staff, 66.7% of postgraduate had the knowledge, followed by medical degree (57%). However, among graduating students, 76.4% did not have enough knowledge of Pap smear [Table 3].
|Table 3: Association between educational level and the level of knowledge of Pap smear among SQUH gynecological outpatients, SQU staff and students|
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The majority of the SQUH outpatients (92.2%), SQU medical staff (91.7%) and students (85.4%) had no financial problems that may have affected their regular visits to the gynecological examination. Furthermore, 70-96% of the three groups believed that Pap smear screening test can lead to more successful prevention and treatment for cervical cancer [Table 4].
|Table 4: Distribution of SQUH gynecological outpatients, SQU staff and students by their attitudes and personal believes toward Pap smear|
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Overall, 36.8% of outpatients who participated in the study had performed Pap smear. In comparison with the SQU medical staff, only 23.3% performed the test previously. None of the SQU students performed the test.
The performance status among the outpatients and staff were compared with their marital status. A significant difference was found among staff only (p =0.003). P value could not be obtained for student group since none of them performed Pap smear [Table 5].
|Table 5: Association between marital status and the Pap smear performance status among SQUH gynecological outpatients, SQU staff and students|
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The performance status among the outpatients and staff were compared with their educational level, it was found that there was a significant difference between the performance status and the educational level among outpatients (p = 0.031). On the other hand, the educational level of the medical staff was distributed disproportionately between undergraduate, medical university degree and postgraduate, and there was no significant difference between their level of education and the performance of Pap smear (p> 0.05) [Table 6].
|Table 6: Association between educational level and Pap smear performance status among SQUH gynecological outpatients, SQU staff and students|
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When the participants were asked regarding the main motivating factors that encouraged the participants to perform Pap smear, out of the 36.8% of SQUH outpatients who performed the test before, majority of them (32.4%) said that they were reminded by their health professional who advised them to perform the test. The main motivating factors among the total staff (23.3%) who performed the test was understanding the importance of the screening even when symptoms are absent, that is 16.5%, this reason was also obvious in outpatients (16.2%), as the third main motivating factor. Regarding the students who participated in this study, none of them performed the test before. Thus, no motivating factors could be evaluated [Figure 1].
|Figure 1: Motivating factors of Pap smear performance among SQUH gynecological outpatients, SQU staff and students|
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When barriers of not performing Pap smear were investigated, 39% of the total outpatients reported that they are not familiar with the test or they never heard of Pap smear. Among the medical staff, the main barriers were among those who believed that they do not need this screening test because they are not married yet or still young (31.6%). When the barriers were investigated with the students, more than half (65.1%) reported that they are not familiar with, or never heard of Pap smear, this barrier was also the main one among the outpatients [Table 7].
|Table 7: Barriers affecting Pap smear performance among SQUH gynecological outpatients, SQU staff and students|
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| Discussion|| |
Performance of Pap smear, as one of the most effective procedure for screening of cervical cancer, is highly influenced by variety of individual and social factors including: socio-demographic characteristics, knowledge of Pap smear, attitudes and personal believes toward the test as well as many other factors that may influence the performance status of the women. This study aimed to assess the level of Pap smear knowledge as well as the performance status among the three groups (SQUH gynecological outpatients, SQU medical staff and students) and how these two main variables can be influenced by other factors.
Nearly half of the gynecological outpatients had adequate knowledge of Pap smear. This result was expected since they have frequent visits to the gynecological department, during their pregnancies, for frequent checkups and due to many health problems in female genital tract such as vaginal bleeding and oligomenorrhea. In addition, this adequate knowledge was found mainly in women between 30-40 years old. These findings are consistent with a study carried out in Sao Paulo, Brazil.
The level of Pap smear knowledge among staff (56.4%) was slightly lower compared to outpatients, despite their high level of medical education. However, this finding is much more better than those found in study performed among interns and nursing staff in Pakistan, where only 40% of them, were able to recognize Pap smear as a screening tool for cervical cancer.
On the other hand, students were reported with the lowest percentage (23%). This result was somehow unexpected also; giving that the students in a college environment is more exposed to public health education messages on screening tests of the significant public health burdens such as cervical cancer. But the findings were similar to what was found in a study targeted college women in a university in Ghana. However, since 97% of the students participated in our study were still single, this may explain their poor knowledge toward Pap smear.
Marital status and educational level were not associated with the knowledge score among the three categories (p> 0.05), this finding is in line to a similar study in KhonKaen University, in Thailand and in contrast to a study conducted in Nigeria in which separated or divorced women had a higher level of Pap smear knowledge. Our results may indicate that insufficient information about the cervical cancer and Pap test are taught to the females in their secondary school, or even in the medical colleges for the staff specifically.
With regards to the attitudes and personal believes toward the Pap test, all the participants reflected an appropriate attitude, where more than 70% from each group (outpatients, medical staff and students) believed that Pap smear screening test can lead to more successful prevention and treatment for cervical cancer. In addition, about 90% of each category denied any family believes or financial conditions that may affect their regular gynecological examinations. This is due to the fact that Pap smear is funded by the government in the Sultanate of Oman, thus women do not have to pay to perform the test, except in the private hospitals. This is not the case in Ghana, in which the expensive cost of Pap smear was the first factor that limited the setting up of such test among population.
When the participants were asked about the importance of Pap smear, majority of them (96.6% of outpatients, 89.5% of the medical staff and 72% of the students) considered it as a very important test for screening of cervical cancer. This finding, among the three categories, reflects good attitudes and beliefs regardless their actual knowledge about the test itself. The same question was asked in a study involving gynecological outpatients, interns and nursing staff and college students in Ghana. 16% of the outpatients did not know the purpose of the test, while only 40% of the medical staff recognized the exact purpose of Pap smear. Among the female students in Ghana, there was an inadequate believes toward the importance of the cervical smear.
Regarding the other questions that assessed the personal beliefs toward Pap smear, the results showed a positive association between the physician gender and the performance status among the medical staff. It revealed that the staff was more willing to perform the test if their health provider is female, this may be due to the conservative nature of our society. Such association was not found among the outpatients and students. This may be explained by the fact that the health professionals know much more about the exact Pap smear procedure than other members in the population. Moreover, the study results showed that the percentage of the outpatients who underwent Pap smear increases because of their belief that the test results are reliable in our hospitals; this may reflect a good health facilities provided to the population in Oman.
Regarding Pap test performance, outpatients, staff and students showed 36.8%, 23.3% and none of the students who participated in the study had the test before, respectively. The educational level and marital status of the outpatients showed a strong and positive association with the uptake of Pap smear. The correlation between higher education level and increased cervical cancer screening attendance is also supported by similar studies in Mexico and Jamaica.,
Moreover, the positive influence of physician recommendations on Pap smear uptake has been well defined among the outpatients. This indicates the influence of physicians on the patients decisions regarding their health. This finding is in line with other study. However, 16% of the participants stated that they understood the importance of the cervical screening test even in the absence of symptoms, and other reported that they reached to the age where performing Pap smear is necessary. The last two factors found to be the main motivating reasons among the medical staff as well. Other study found different motivating factors for screening such as generic perceived risk due to HIV status and being sexually active.
We should point out some weaknesses in this study. First, the study was restricted to participants from a single hospital and university, even though this hospital serves as a tertiary referral hospital in Oman and the university is the national university of the Sultanate of Oman. Second, we excluded the rural areas in this study. Thus, we cannot generalize the data to all Omani women. Third, students and staff were asked to fill online self-administered questionnaire instead of interview-based questionnaire, as with outpatients, which might bias the study.
Generally, this study has clarified the need for further studies to validate these findings and to focus more in each category independently to further identify the main factors that affect the level of Pap smear knowledge and the uptake of its screening test. The suggested recommendations may include public health education to inform the community about the importance of Pap smear and its role in early detection and prevention of cervical cancer. Such as, strengthen of the education programmes in school, especially for teenage girls, about cervical cancer screenings test. Increase education and counselling services for women attending obstetric and gynecological department. More attention have to be placed on curriculum taught in undergraduate medical school and a proper medical education programs should be established at the hospital level along with seminars, because by this way we can further increase the knowledge, attitudes and practices of Pap smear.
| Conclusions|| |
The findings of this study show poor knowledge and performance of Pap smear test and good attitude towards Pap smear. Healthcare recommendation and understanding the importance of Pap smear are the main motivating factors among the outpatients and medical staff, respectively. The common barrier that prevents the uptake of Pap test among patients, staff and students is the belief that they have a healthy lifestyle without obvious symptoms. More public health education is required to inform the community about the importance of Pap smear as well as to strengthen the curriculum taught in undergraduate university.
We would like to thank all women who participated in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Nooyi SC, Al-Lawati JA. Cancer incidence in Oman, 1998-2006. Asian Pac J Cancer Prev 2011;12:1735-38.
Naidu S, Helle G, Qalomaiwasa G, Naidu S, Gyaneshwar R. Knowledge, attitude, practice and barriers regarding cervical cancer and its screening using Pap smear, in rural women of Ba, Lautoka and Nadi, Fiji. Pac J Reprod Health 2015;1:50-9.
Obeidat B, Amarin Z, Alzaghal L. Awareness, practice and attitude to cervical Papanicolaou smear among female health care workers in Jordan. Eur J Cancer Care 2011;21:372-6.
Strohl A, Mendoza G, Ghant M, Cameron K, Simon M. Schink et al
. Barriers to prevention: knowledge of HPV, cervical cancer, and HPV vaccinations among African American women. Am J Obstet Gynecol 2015;212:e1-e5.
Albuquerque C, Costa M, Nunes F, Freitas R, Azevedo P, Fernandes J. et al
. Knowledge, attitudes and practices regarding the Pap test among women in north eastern Brazil. Sao Paulo Med J 2014;132:3-9.
Ali S, Ayub S, Manzoor N, Azim S, Afif M, Akhtar N. et al
. Knowledge and awareness about cervical cancer and its prevention amongst interns and nursing staff in tertiary care hospitals in Karachi, Pakistan. PLoS ONE 2010;5:e11059.
Abotchie P, Shokar N. Cervical cancer screening among college students in Ghana. Int J Gynecol Cancer 2009;19:412-6.
Nganwai P, Truadpon P, Inpa C, Sangpetngam B, Mekjarasnapa M, Apirakarn M. et al
. Knowledge, attitudes and practices vis-a-vis cervical cancer among registered nurses at the Faculty of Medicine, KhonKaen University, Thailand. Asian Pac J Cancer Prev 2008;9:15-8.
Anya SE, Oshi DC, Nwosu SO, Anya AE. Knowledge, attitude, and practice of female health professionals regarding cervical cancer and Pap smear. Niger J Med 2005;14:283-6.
Bingham A, Bishop A, Coffey P, Winkler J, Bradley J, Dzuba I. et al
. Factors affecting utilization of cervical cancer prevention services in low-resource settings. Salud Pública Méx 2003;45:408-16.
Jolly P, Bessler P, Ncube B, Bey A, Knight J. Factors associated with the uptake of cervical cancer screening among women in Portland, Jamaica. North Am J Med Sci 2015;7:104-13.
] [Full text]
Bukirwa A, Mutyoba J, Mukasa B, Karamagi Y, Odiit M, Kawuma E. et al
. Motivations and barriers to cervical cancer screening among HIV infected women in HIV care: a qualitative study. BMC Women's Health 2015;15:1.
Nasar Yousuf Alwahaibi
Department of Allied Health Sciences College of Medicine and Health Sciences Sultan Qaboos University, Muscat
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]