Keywords Attitude - cervical cancer - human papillomavirus - knowledge - Malaysia - Pap smear
- practice
Introduction
Globally, cervical cancer (CC) is the fifth leading cause of cancer-related deaths
among women after cancers of breast, lung, stomach, and colorectal and a good portion
remains with the developing countries.[1 ]
[2 ]
[3 ]
[4 ]
[5 ]
[6 ] Paradoxically, distinct CC from most other cancers, as can be preempted through
proper screening strategies and to reduce both morbidity, mortality and improves quality
of life.[7 ] There are about 500,000 new incidences of CC and CC-related morbidity and mortality
identified each year and about 80% of these occur in the developing countries,[8 ] usually with less comprehensive CC prevention programs.[9 ] In Malaysia, constituting 12.9% of all female cancers, CC was placed as the second-most
common female cancer. The Malaysian National Cancer Registry reported an average of
2000–3000 hospital admissions of CC annually. According to the report, most of the
admission presented in the late stages of the disease.[10 ] In contrast to developing countries, the morbidity and mortality of invasive CC
have dramatically declined in the last 50 years in some developed countries. Adequate
application of mass routine screening with Pap smear was found to be helpful in preventing
and reducing the incidence of this deadly invasive CC.[11 ] The incidence of CCs is commonly associated with human papillomavirus (HPV) infection,
which is one of most common sexually transmitted diseases globally, and no symptoms
might be traced after the infection. HPV infections are associated with the development
of the CC, cervical neoplasia, and other anogenital cancers.[12 ] Oncogenic types of HPV may lead to cancer of the cervix, anus, vagina, vulva, penis,
mouth, and sinuses with persistent HPV viral infection. HPV also causes genital warts,
other chronic infections, nutritional imbalance, hormonal and psychological factors,
along with other suppressive factors.
The risk of CC among females may increase in those who had sex at an early age and
with multiple sexual partners. Uncircumcised males were also found to contribute towards
the HPV infection to their partners through sexual intercourse.[13 ] HPV infection alone is not an ample cause of CC. Besides, lower socioeconomic status,
smoking, high parity, long-term oral contraceptive use and herpes, and chlamydial
infections are also possible co-factors of CC.[8 ] Pap smear is named after the founder of the test, Dr. George Papanicolaou.[14 ] In 1928, Dr. G Papanicolaou discovered the appearance of cervix cells change in
the process of becoming cancerous cells through the Pap smear test. Pap smear is an
important CC screening test. Precancerous cells may lead to the development of cancer
in endocervical canal which is known as CC if left untreated.[15 ] Pap smear screening was first introduced in Malaysia in 1981 to the family planning
acceptors and 1995; the screening was extended to all women aged 20–65 years.[16 ] Women can have Pap smear done in the gynecological clinic, maternity home, practitioner
clinic, or hospital. If a woman has a routine Pap smear done regularly, any cervical
abnormality, or CC can be detected earlier. It is recommended that every woman aged
21-year-old and older has sex needs regular Pap smear testing done every 2 years.
Most women after the age of 65–70 years can stop having Pap smear done if they have
had three negative tests within the past 10 years. If they have a new sexual partner
after the age of 65 years, they should begin having Pap smear screening again.[17 ]
[18 ]
Objective of the study
(i) To find the association between knowledge, attitude and practice (KAP) concerning
Pap smear, CC, and HPV among mothers attending a Mother and Child Health Clinic in
Kuantan. (ii) To find the relationship between age of the mothers with KAP concerning
Pap smear, CC and HPV. (iii) To compare the KAP concerning Pap smear, CC, and HPV
among mothers from Malay, Chinese, Indian, and other races.
Materials and Methods
Study Design: This was a cross-sectional study. The design of this study involved interviewer guided,
structured questionnaire in which the study participants answered. It leads to the
simplicity and feasibility of study execution to provide answers on KAP regarding
Pap smear, CC, and HPV. Study Period and Area: This study was conducted from February
to March 2013 in an MCHC in Kuantan, Malaysia. Source of Population: Women attending
the clinic had been the respondents for this study. Sample Size Calculation: Power
and Sample Size Software was utilized to calculate the sample size. Using the significance
level of 0.05, power of study of 0.8, the sample ratio of 1, the detectable difference
of 0.8, and the standard deviation of 2.0,[19 ] resulting in the sample size 109 (including 10% nonresponse rate). Sampling Method: Convenience sampling was used. They were selected among women attending the MCHC
according to the inclusion and exclusion criteria. The inclusion criteria were as
follows (i) women attending the MCHC in Kuantan, (ii) at least first pregnancy, and
(iii) speaks Malay or English. The exclusion criteria were as follows (i) age under
18-year-old and (ii) mentally unhealthy. Data Collection Tool: Data had been obtained through interviewer guided structured questionnaire. A brief
explanation was given along with an information sheet which was provided before the
questionnaire. The questionnaire contained four sections: Section A was targeted to
obtain the sociodemographic information, while Section B was attempted to assess the
knowledge of the respondents regarding Pap smear, CC, and HPV. Every question in Section
B was presented with “True” or “False” or “Do Not Know” choices of answers. Section
C provided the questions to measure the attitude of respondents towards Pap smear,
CC, and HPV in which the answer choices included either “Agree,” “Disagree,” or “Not
Sure,” and Section D contained questions to gather the details on the practice of
the respondents regarding Pap smear and HPV vaccination. In Section D, respondents
needed to choose or state how often they have Pap smear screening and HPV vaccination.
Respondents completed the questionnaire under the supervision of the researcher. Data Management and Analysis: Utilizing Statistical Package for Social Sciences software, (IBM Corporation. Armonk,
New York, USA) the data collected were analyzed using both descriptive and inferential
statistics. Ethical Approval: It was given by the Medical Research Ethics Committee in their letter No (2) dlm.
KKM/NIHSEC/800-2/2/2/P13-236.
Results
Respondents' characteristics
A total of 120 respondents were involved in this study including mothers attending
the MCHC in Kuantan. The respondents' sociodemographic characteristics were obtained
through the first part of the questionnaire. The range of the respondents' age was
18–57 years old with the mean of 32.19 ± 7.092. Most of the respondents were married
(99.2%) while only 1 (0.8%) respondent was in divorced status. Majority of the responses
were recorded in Malay (82.5%, n = 99), followed by Chinese 11.7% (14) and/or Indian 5.8% (7). The majority (48.3%
(58) of respondents were with tertiary education, followed by secondary education
(46.7% (56). Those with primary education and other educational level shared the same
result with only 25% (3) respondents each. 43.3% (52), 26.7% (32), 17.5% (21), and
12.5% (15) respondents were housewives, public servants, private sector and other,
and self-employed and pensioners, respectively.
Knowledge of the respondents regarding Pap smear, cervical cancer, and human papillomavirus
Majority (81.7% (98) of respondents knew about the relationship of Pap smear with
CC [Table 1 ]. Over 84 (70%) respondents knew that cervical cells could be used as sample in Pap
smear and 91 (75.8%) respondents also understood the ability of Pap smear to detect
precancerous cells in the cervix. Less than half (23.3% (28) of the respondents were
aware that recommendation to have Pap smear is not every 5 years, only 2.5% (3) respondents
knew that Pap smear should be started earlier than the age of 60-year-old and majority
of 70.8% (85) respondents were aware that Pap smear is recommended after getting married.
Most of the respondents were aware that Pap smear is done to check for infections
transmitted through sex (59.2% (71), cancer or early changes of cancer in the cervix
(n = 97 or 80.8%) while none understood that Pap smear is not for detecting the infections
transmitted by blood transfusion. More than half (61.7% (74) of the respondents knew
that the sign and symptom of CC is abnormal bleeding from the vagina. They were also
aware that pelvic pain (67.5% (81) and itching outside vagina (21.7% (26) are not
signs and symptoms of CC. The respondents also knew that one can be at a greater risk
of CC if sexual intercourse started at an early age (55.8% (67) and with multiple
sexual partners (60.8% (73). Only 8.3% (10) respondents knew that obesity is not the
cause of CC. Moreover, 45.8% (55) respondents were aware that HPV is a sexually-transmitted
infection that may cause CC.
Table 1
Knowledge of respondents regarding Pap smear, cervical cancer, and human papillomavirus
(n =120)
Statements
n (%)
True
False
Don’t know
*Correct answers are highlighted in bold. CC - Cervical cancer; HPV - Human papillomavirus
Pap smear screening test is related to CC
98 (81.7)
0 (0.0)
22 (18.3)
Pap smear test using cervical cells as sample
84 (70.0)
2 (1.7)
34 (28.3)
Pap smear detects precancerous cells before symptoms occur
91 (75.8)
1 (0.8)
28 (23.3)
It is recommended that the woman to have a Pap smear screening test
For at least every 5 years
39 (32.5)
28 (23.3)
53 (44.2)
From the age of 60-year-old
76 (63.3)
3 (2.5)
41 (34.2)
After getting married
85 (70.8)
7(5.8)
28 (23.3)
Pap smear screening is done on women to check for
Infections transmitted through sex
71 (59.2)
16 (13.3)
33 (27.5)
Infections transmitted by blood transfusion
64 (53.3)
0 (0.0)
56 (46.7)
Cancer or early changes of cancer in the cervix
97 (80.8)
3 (2.5)
20 (16.7)
The signs and symptoms for the CC include
Abnormal bleeding from vagina
74 (61.7)
4 (3.3)
42 (35.0)
Pelvic pain
0 (0.0)
81 (67.5)
39 (32.5)
Itching outside vagina
33 (27.5)
26 (21.7)
61 (50.8)
Those at greater risk for developing CC is the women
Who had sexual intercourse at an early age
67 (55.8)
6 (5.0)
47 (39.2)
With obesity problem
45 (37.5)
10 (8.3)
65 (54.2)
With multiple sexual partners
73 (60.8)
4 (3.3)
43 (35.8)
HPV is sexually-transmitted infection that may cause CC
55 (45.8)
3 (2.5)
62 (51.7)
Attitude of the respondents regarding Pap smear and cervical cancer
About 80.8% (97) of respondents agreed they will be satisfied after knowing their
Pap smear test result [Table 2 ]. Most respondents 85.8% (103) believed that regular practice of Pap smear is important
as and will give them a sense of control. Most of the respondents disagreed that the
procedure of Pap smear is unpleasant 54.2% (65), embarrassing 41.7% (50), and painful
43.3% (52). More than half (70% (84) of the respondents showed a positive attitude
towards going to a Pap smear clinic while 70.8% (85) respondents believed that Pap
smear is necessary even in the absence of any sign or symptom of CC. Most respondents
agreed that Pap smear test is not expensive (54.2% (65) and takes a short duration
(50.8% (61). Half of the respondents (50% (60) disagreed that they are afraid that
something wrong will be detected through Pap smear test and believed that they are
still at risk for CC even if they take good care of their health. Most of the respondents
(63.3% (76) also disagreed that they are not at risk for CC if they have no family
history of that cancer.
Table 2
Attitude of the respondents regarding Pap smear, cervical cancer, and human papillomavirus
(n =120)
Statements
n (%)
Agree
Disagree
Not sure
*Expected answers are highlighted in bold. CC - Cervical cancer
I will be satisfied after knowing my Pap smear test result
97 (80.8)
2 (1.7)
21 (17.5)
It is important to have Pap smear regularly
103 (85.8)
0 (0.0)
17 (14.2)
Having regular Pap smear test give me a sense of control
103 (85.8)
0 (0.0)
17 (14.2)
Having a Pap smear test is
Unpleasant
18 (15.0)
65 (54.2)
37 (30.8)
Embarrassing
36 (30.0)
50 (41.7)
34 (28.3)
Painful
19 (15.8)
52 (43.3)
49 (40.8)
It is difficult to get to the clinic to have Pap smear test
14 (11.7)
84 (70.0)
22 (18.3)
Pap smear is unnecessary if there is no sign and symptom
7 (5.8)
85 (70.8)
28 (23.3)
Having a Pap smear test
Is too expensive
3 (2.5)
65 (54.2)
52 (43.3)
Takes too much time
8 (6.7)
61 (50.8)
51 (42.5)
I am afraid that something wrong will be detected if I go for a Pap smear test
30 (25.0)
60 (50.0)
30 (25.0)
If I take good care of my health by exercising and eating right, I am not at risk
for CC
26 (21.7)
60 (50.0)
34 (28.3)
I am not at risk for CC because I have no my family history of that cancer
4 (3.3)
76 (63.3)
40 (33.3)
Practice of the respondents regarding Pap smear and human papillomavirus vaccination
In the past 5 years from 2009 to 2013, majority (n = 65; 54.2%) of the respondents had never had a Pap smear test done. While 33 (27.5%)
of respondents had done the screening once, 18 (15%) had twice and only 4 (3.3%) respondents
had the screening done more than three times. Over 81 (67.5%) of respondents did not
receive HPV vaccination while 39 (32.5%) did receive the vaccination.
Association between knowledge, attitude, and practice regarding Pap smear, cervical
cancer, and human papillomavirus
Pearson correlation test was used here because the linearity and normality assumptions
were satisfied. The knowledge and attitude regarding Pap smear, CC, and HPV is positively
significantly correlated (r = 0.500, P < 0.001), also between attitude and practice (r = 0.409, P < 0.001) [Figure 1 ] and [2 ]. However, there is no significant correlation between practice and knowledge regarding
Pap smear, CC, and HPV (r = −0.059, P = 0.525) [Figure 3 ].
Figure 1: Association between knowledge and attitude regarding Pap smear, cervical
cancer, and human papillomavirus
Figure 2: Association between attitude and practice regarding Pap smear and cervical
cancer
Figure 3: Association between practice and knowledge regarding Pap smear and human
papillomavirus vaccination
Association between mean age of the respondents with knowledge, attitude, and practice
regarding Pap smear, cervical cancer, and human papillomavirus
Similarly, Pearson correlation test was used to assess the association here. The age
and knowledge regarding Pap smear, CC, and HPV are not significantly correlated (r = −0.069, P = 0.455). However, there is positive significant correlation between age and attitude
regarding Pap smear and CC (r = 0.231, P = 0.011), also between age and practice regarding Pap smear and HPV vaccination (r = 0.472, P < 0.001). The correlation between age with KAP regarding Pap smear, CC, and HPV are
illustrated [Figures 4 ], [5 ], [6 ]
Figure 4: Association between age and knowledge regarding Pap smear, cervical cancer,
and human papillomavirus
Figure 5: Association between age and attitude regarding Pap smear and cervical cancer
Figure 6: Association between age and practice regarding Pap smear and human papillomavirus
vaccination
Association between races of the respondents with knowledge, attitude, and practice
regarding Pap smear, cervical cancer, and human papillomavirus
Nonparametric test was used to compare the KAP regarding Pap smear, CC, and HPV between
races. This type of test was used because the sample size of “Others” group (Chinese
and Indian) was <30 and not normally distributed. As illustrated in [Table 3 ], there is a statistically significant difference in comparing knowledge and attitude
regarding Pap smear, CC, and HPV between Malay and other races (Chinese and Indian),
whereby the knowledge and attitude among Malays is higher as compared to other races,
while the difference is not significant for practice regarding Pap smear and HPV vaccination.
Table 3
Comparing knowledge, attitude and practice regarding Pap smear, cervical cancer, and
human papillomavirus between races using Mann-Whitney test (n =120)
Variance
Median (IQR)
Z
P
Malay (n =99)
Others (n =21)
IQR - Interquartile range
Knowledge
38.00 (4)
37.00 (8)
-2.037
0.042
Attitude
34.00 (9)
28.00 (22)
-2.627
0.009
Practice
3.00 (2)
2.00 (2)
-1.542
0.123
Discussion
Sociodemographic characteristics
The majority of the 120 respondents who participated in this study were Malaysian.
This might be because the study had been done in a government clinic which Malaysian
as top priority to have medical checkup and treatment. The range of respondents' age
was 18–57 years and the mean age was 32.19 years. Most of them were Malay and married.
This might be due to the high numbers of Malay in the communities. The majority of
respondents attained a secondary and tertiary education level, and over half of them
were homemakers.
Knowledge of respondents regarding Pap smear, cervical cancer, and human papillomavirus
Most of the respondents did know the use of Pap smear in detecting and preventing
CC. However, [20 ] Besides that, knowing the signs and symptoms are also important in curing and preventing
CC. Most of the respondents knew that abnormal bleeding from vagina can be a sign
of CC while they also knew that pelvic pain and itchiness outside vagina are not included
in the signs and symptoms of CC. Less concrete knowledge on the signs and symptoms
of CC might be due to the lack of information and awareness in women. Respondents
were mostly aware that those who had sexual intercourse at an early age and with multiple
sexual partners are at greater risk for developing CC. Apart from that, over half
of them knew the association between HPV and CC. Optimizing the use of mass media
plays an important role in educating women regarding the etiology of CC, how the HPV
contributes to the cancer as well as effective methods in preventing CC.[21 ]
Attitude of respondents regarding Pap smear, cervical cancer, and human papillomavirus
Majority of the respondents agreed that they would be satisfied after the Pap smear
was done and they also realized the importance of regular Pap smear screening in giving
them the sense of control. Over half of them disagreed that the procedure of Pap smear
test is unpleasant, embarrassing, and painful. Another study found that embarrassment
can be a reason why the female patients avoiding Pap smear screening.[22 ] This might be due to the cultural influences of the female patients. Unpleasant
and painful procedure was reported to be a barrier for women to have Pap smear done.
The patients should be encouraged to be in relaxing condition which can be of help
for them to cope with the concerns about pain and discomfort during Pap smear test.[21 ] More than half of the respondents agreed that it is not difficult to go to clinic
to have Pap smear as clinics or hospitals are available near all the places around
Kuantan. Many of them also agreed that Pap smear is necessary even in the absence
of signs or symptoms of CC. CC is preventable as Pap smear screening identifies the
precancerous lesions earlier and the progression of the lesions into cancer can be
stopped with early treatment.[23 ]
Most of the respondents agreed that Pap smear test is affordable and takes a little
time. One Malaysian study found that socioeconomic barriers such as illiteracy, treatment
cost, and lack of transportation as well as childcare problem also can be the factors
of low uptake of Pap smear screening among women.[16 ] The current study found that over half of the respondents were not afraid if their
Pap smear test would detect something wrong. Women were found to be in fear if the
Pap smear test may elicit abnormal results which would cause them to avoid routine
Pap smear screening.[21 ] Most of the respondents believed that they were at risk even if they take good care
of their health, and even also they have no family history of CC. HPV infection is
one of the risk factors for CC as well as lack of routine Pap smear, multiple sexual
partners, smoking, and others. Although previous family history of this cancer is
not considered as a risk factor for CC, women who are exposed to other risk factors
may develop this cancer.[24 ]
Practice of respondents regarding Pap smear, cervical cancer, and human papillomavirus
This study found that most of the respondents never had Pap smear in the past 5 years
and more than half of them never had HPV vaccination. Lack of encouragement and awareness
of Pap smear screening might contribute to the lower practice of Pap smear screening.[9 ] Medical practitioners also play an important role in providing and promoting knowledge
and awareness regarding Pap smear screening to female patients.[22 ] Medical practitioners should have high level of knowledge as well as satisfactory
attitude and practice regarding Pap smear and HPV vaccination so that they could persuade
the female patients to have Pap smear screening and HPV vaccination.
Association between knowledge, attitude, and practice regarding Pap smear, cervical
cancer, and human papillomavirus
The results show that there was significant correlation between knowledge with attitude
(P < 0.001) and attitude with practice (P < 0.001) of the respondents regarding Pap smear, CC and HPV. The result can be concluded
that knowledge of respondents contributes to their attitude towards Pap smear, CC,
and HPV. Lack of knowledge may contribute to low level of attitude of respondents.
Like the relationship between attitude and practice, high level attitude of respondents
motivates the practice regarding Pap smear, CC, and HPV. However, there were no significant
correlation between knowledge with practice among respondents regarding Pap smear,
CC, and HPV. Having knowledge did not contribute to the practice of Pap smear screening
and HPV vaccination. Some barriers such as no encouragement from partners or medical
practitioners and lack of women health programs shun the women from having Pap smear
screening and HPV vaccination.[21 ]
Association between age of the respondents with knowledge, attitude, and practice
regarding Pap smear, cervical cancer, and human papillomavirus
Based on the results, age of the respondents was not significantly associated with
their knowledge regarding Pap smear, CC, and HPV (P = 0.455). The knowledge was not dependent on the age of the respondents as it depends
on the frequency of information about Pap smear, CC, and HPV exposed to the respondents
regardless of age. Nevertheless, there were significant association between age with
attitude (P = 0.011) and practice (P < 0.001) regarding Pap smear, CC, and HPV. Most of respondents at an older age were
keen in ensuring their health which contributes to the escalating of their attitude
and practice regarding Pap smear, CC, and HPV. Women at younger age have unsatisfactory
attitude and practice of Pap smear, CC, and HPV since they may think that they are
not vulnerable of having CC at their current age.[24 ]
Association between races with knowledge, attitude, and practice regarding Pap smear,
cervical cancer, and human papillomavirus
The results show that there was significant difference between Malay and other races
in term of knowledge and attitude regarding Pap smear, CC, and HPV (P < 0.05). Most of the respondents were Malay hence they contributed to the significant
difference in the association. However, there was no significant difference between
races with practice of Pap smear, CC, and HPV (P > 0.05). The practice is depending on the willingness of an individual to have Pap
smear screening and HPV vaccination or not. Besides, recommendation from the medical
practitioners may persuade the women to have routine Pap smear screening and HPV vaccination
in ensuring their health.
Conclusions
This study concluds that the knowledge of women varies according to their sociodemographics
background. Most respondents never had HPV vaccination and Pap smear screening. Most
of them were not certain about the recommendation of Pap smear for the women are every
3 years. The practice of Pap smear can be increased by educating women about the importance
of Pap smear in preventing CC.
Future work recommendation
Education about Pap smear, CC, and HPV needs to be introduced into the secondary educational
level as well as in maternal clinic and hospital outpatients as to improve the awareness
regarding Pap smear, CC, and HPV. Mass media like advertisement in television and
radio should also be made available.
