Abstract

Background: Cervical cancer (CC) is a foremost reason of global cancer death in women, and a good portion remains with the developing countries. This study was conducted to assess the knowledge, attitude, and practice regarding Pap smear, CC, and Human Papillomavirus (HPV) among the women attending a Mother and Child Health Clinic in Kuantan, Malaysia. Materials and Methods: A total of 120 respondents involved in this cross-sectional study. The convenience sampling was to select the respondents. The data were collected from in 2013. Results: The mean age 32.19 years. Up to 54.2% of respondents never had Pap smear in the past 5 years, while over 67.5% of respondents never had HPV vaccination. There was a significant correlation between knowledge with attitude (P < 0 class="i" xss=removed>P < 0 class="i" xss=removed>P = 0.525). There was no significant correlation between mean age and knowledge (P = 0.455) while there was a significant correlation between mean age with attitude (P = 0.011) and practice (P < 0 class="i" xss=removed>P < 0 class="i" xss=removed>P > 0.05) between races. Conclusions: Important barriers to Pap smear screening among women are highlighted through this study. The health institution involved needs to come up with better strategies to deal with these barriers to improve the awareness of women regarding Pap smear, CC, and HPV.

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.

| 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 href="https://www.thieme-connect.com/products/ejournals/html/10.4103/ijmpo.ijmpo_199_17#FI_4" xss=removed>Figures 4], [5], [6]

| Figure 4  Association between age and knowledge regarding Pap smear, cervical cancer, and human papillomavirus

| 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 href="https://www.thieme-connect.com/products/ejournals/html/10.4103/ijmpo.ijmpo_199_17#TB_3" xss=removed>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.

1. Singh S, Badaya S. Factors influencing uptake of cervical cancer screening among women in India: A hospital based pilot study. J Community Med Health Educ 2012; 2: 157
2. Kaarthigeyan K. Cervical cancer in India and HPV vaccination. Indian J Med Paediatr Oncol 2012; 33: 7-12
3. Sheikh SA, Haque M, Ismail S, Hussein UY, Simbak NB. Knowledge and attitudes toward HPV vaccination among healthcare givers:First multicenter survey in Malaysia. AMJ 2017; 10: 361-72
4. Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical cancer and role of screening in India. Indian J Med Paediatr Oncol 2016; 37: 278-85
5. Sheikh SA, Simbak NB, Ismail SB, Rahman NI, Rebuan HM, Dali WP. et al. A pilot survey of awareness and knowledge of human papillomavirus (HPV), cervical cancer and HPV vaccine among men and women attending for HPV vaccination in Terengganu, Malaysia. Int J Pharm Sci Rev Res 2015; 31: 242-6
6. Mahantshetty U, Krishnatry R, Kumar S, Engineer R, Maheshwari A, Kerkar R. et al. Consensus meeting and update on existing guidelines for management of cervical cancer with special emphasis on the practice in developing countries, including India: The expert panel at the 8th annual women's cancer initiative Tata Memorial Hospital Conference 2010-11. Indian J Med Paediatr Oncol 2012; 33: 216-20
7. Mishra GA, Pimple SA, Shastri SS. An overview of prevention and early detection of cervical cancers. Indian J Med Paediatr Oncol 2011; 32: 125-32
8. Chekuri A, Bassaw B, Affan AM, Habet G, Mungrue K. Knowledge, attitudes, practice on human papilloma virus and cervical cancer among Trinidadian women. J Obstet Gynaecol 2012; 32: 691-4
9. Hyacinth HI, Adekeye OA, Ibeh JN, Osoba T. Cervical cancer and pap smear awareness and utilization of pap smear test among federal civil servants in North Central Nigeria. PLoS ONE 2012; 7: e46583
10. Fatt LS. Mass Human Papilloma Virus (HPV) Vaccination of Women in the General Population; 2012. Available from: http://www.medicine.com.my/wp/2012/01/mass-human-papilloma-virus-hpv -vaccination-of-women-in-the-general-population/. [Last accessed on 2017 Sep 19]
11. Reis N, Bebis H, Kose S, Sis A, Engin R, Yavan T. et al. Knowledge, behavior and beliefs related to cervical cancer and screening among Turkish women. Asian Pac J Cancer Prev 2012; 13: 1463-70
12. Chelimo C, Wouldes TA. Human papillomavirus knowledge and awareness among undergraduates in healthcare training in New Zealand. N Z Med J 2009; 122: 33-45
13. Jahan F, Nabi N, Qidwai W, Borhany T, Hossein S, Azam I. Frequency of abnormal pap smear and assessment of risk factors for cervical cancer in an outpatient clinic. J Dow Univ Health Sci 2008; 2: 55-9
14. Tan SY, Tatsumura Y. George papanicolaou (1883-1962): Discoverer of the pap smear. Singapore Med J 2015; 56: 586-7
15. Canadian Cancer Society. Precancerous Conditions of the Cervix; 2017. Available from: http://www.cancer.ca/en/cancer-information/cancer-type/cervical/cervical -cancer/precancerous-conditions/?region=bc. [Last accessed on 2017 Sep 17]
16. Asmani AR, Aziah D. PAP smear screening practice among women in Mukim Jaya Setia, Kelantan. Malay J Public Health Med 2007; 7: 20-4
17. Yang KY. Abnormal pap smear and cervical cancer in pregnancy. Clin Obstet Gynecol 2012; 55: 838-48
18. Teoh DG, Marriott AE, Isaksson Vogel R, Marriott RT, Lais CW, Downs Jr. LS. et al. Adherence to the 2012 national cervical cancer screening guidelines: A pilot study. Am J Obstet Gynecol 2015; 212: 62.e1-9
19. Mehmetoglu HC, Sadikoglu G, Ozcakir A, Bilgel N. Pap smear screening in the primary health care setting: A study from Turkey. N Am J Med Sci 2010; 2: 467-72
20. Othman NH, Devi BC, Halimah Y. Cervical cancer screening: Patients understanding in major hospitals in Malaysia. Asian Pac J Cancer Prev 2009; 10: 569-74
21. Al-Naggar RA, Low WY, Isa ZM. Knowledge and barriers towards cervical cancer screening among young women in Malaysia. Asian Pac J Cancer Prev 2010; 11: 867-73
22. Oranratanaphan S, Amatyakul P, Iramaneerat K, Srithipayawan S. Knowledge, attitudes and practices about the pap smear among medical workers in Naresuan University Hospital, Thailand. Asian Pac J Cancer Prev 2010; 11: 1727-30
23. Al-Dubai SA, Alshagga MA, Al-Naggar RA, Al-Jashamy K, Baobaid MF, Tuang CP. et al. Knowledge, attitudes and barriers for human Papilloma virus (HPV) vaccines among Malaysian women. Asian Pac J Cancer Prev 2010; 11: 887-92
24. Patel HI. Comparisons Among College Students Who Do and Do Not Obtain Routine Pap Smear. Honors Thesis. 2011. Western Michigan University; USA: 2011

| 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

| 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

1. Singh S, Badaya S. Factors influencing uptake of cervical cancer screening among women in India: A hospital based pilot study. J Community Med Health Educ 2012; 2: 157
2. Kaarthigeyan K. Cervical cancer in India and HPV vaccination. Indian J Med Paediatr Oncol 2012; 33: 7-12
3. Sheikh SA, Haque M, Ismail S, Hussein UY, Simbak NB. Knowledge and attitudes toward HPV vaccination among healthcare givers:First multicenter survey in Malaysia. AMJ 2017; 10: 361-72
4. Bobdey S, Sathwara J, Jain A, Balasubramaniam G. Burden of cervical cancer and role of screening in India. Indian J Med Paediatr Oncol 2016; 37: 278-85
5. Sheikh SA, Simbak NB, Ismail SB, Rahman NI, Rebuan HM, Dali WP. et al. A pilot survey of awareness and knowledge of human papillomavirus (HPV), cervical cancer and HPV vaccine among men and women attending for HPV vaccination in Terengganu, Malaysia. Int J Pharm Sci Rev Res 2015; 31: 242-6
6. Mahantshetty U, Krishnatry R, Kumar S, Engineer R, Maheshwari A, Kerkar R. et al. Consensus meeting and update on existing guidelines for management of cervical cancer with special emphasis on the practice in developing countries, including India: The expert panel at the 8th annual women's cancer initiative Tata Memorial Hospital Conference 2010-11. Indian J Med Paediatr Oncol 2012; 33: 216-20
7. Mishra GA, Pimple SA, Shastri SS. An overview of prevention and early detection of cervical cancers. Indian J Med Paediatr Oncol 2011; 32: 125-32
8. Chekuri A, Bassaw B, Affan AM, Habet G, Mungrue K. Knowledge, attitudes, practice on human papilloma virus and cervical cancer among Trinidadian women. J Obstet Gynaecol 2012; 32: 691-4
9. Hyacinth HI, Adekeye OA, Ibeh JN, Osoba T. Cervical cancer and pap smear awareness and utilization of pap smear test among federal civil servants in North Central Nigeria. PLoS ONE 2012; 7: e46583
10. Fatt LS. Mass Human Papilloma Virus (HPV) Vaccination of Women in the General Population; 2012. Available from: http://www.medicine.com.my/wp/2012/01/mass-human-papilloma-virus-hpv -vaccination-of-women-in-the-general-population/. [Last accessed on 2017 Sep 19]
11. Reis N, Bebis H, Kose S, Sis A, Engin R, Yavan T. et al. Knowledge, behavior and beliefs related to cervical cancer and screening among Turkish women. Asian Pac J Cancer Prev 2012; 13: 1463-70
12. Chelimo C, Wouldes TA. Human papillomavirus knowledge and awareness among undergraduates in healthcare training in New Zealand. N Z Med J 2009; 122: 33-45
13. Jahan F, Nabi N, Qidwai W, Borhany T, Hossein S, Azam I. Frequency of abnormal pap smear and assessment of risk factors for cervical cancer in an outpatient clinic. J Dow Univ Health Sci 2008; 2: 55-9
14. Tan SY, Tatsumura Y. George papanicolaou (1883-1962): Discoverer of the pap smear. Singapore Med J 2015; 56: 586-7
15. Canadian Cancer Society. Precancerous Conditions of the Cervix; 2017. Available from: http://www.cancer.ca/en/cancer-information/cancer-type/cervical/cervical -cancer/precancerous-conditions/?region=bc. [Last accessed on 2017 Sep 17]
16. Asmani AR, Aziah D. PAP smear screening practice among women in Mukim Jaya Setia, Kelantan. Malay J Public Health Med 2007; 7: 20-4
17. Yang KY. Abnormal pap smear and cervical cancer in pregnancy. Clin Obstet Gynecol 2012; 55: 838-48
18. Teoh DG, Marriott AE, Isaksson Vogel R, Marriott RT, Lais CW, Downs Jr. LS. et al. Adherence to the 2012 national cervical cancer screening guidelines: A pilot study. Am J Obstet Gynecol 2015; 212: 62.e1-9
19. Mehmetoglu HC, Sadikoglu G, Ozcakir A, Bilgel N. Pap smear screening in the primary health care setting: A study from Turkey. N Am J Med Sci 2010; 2: 467-72
20. Othman NH, Devi BC, Halimah Y. Cervical cancer screening: Patients understanding in major hospitals in Malaysia. Asian Pac J Cancer Prev 2009; 10: 569-74
21. Al-Naggar RA, Low WY, Isa ZM. Knowledge and barriers towards cervical cancer screening among young women in Malaysia. Asian Pac J Cancer Prev 2010; 11: 867-73
22. Oranratanaphan S, Amatyakul P, Iramaneerat K, Srithipayawan S. Knowledge, attitudes and practices about the pap smear among medical workers in Naresuan University Hospital, Thailand. Asian Pac J Cancer Prev 2010; 11: 1727-30
23. Al-Dubai SA, Alshagga MA, Al-Naggar RA, Al-Jashamy K, Baobaid MF, Tuang CP. et al. Knowledge, attitudes and barriers for human Papilloma virus (HPV) vaccines among Malaysian women. Asian Pac J Cancer Prev 2010; 11: 887-92
24. Patel HI. Comparisons Among College Students Who Do and Do Not Obtain Routine Pap Smear. Honors Thesis. 2011. Western Michigan University; USA: 2011