Hindawi

Journal of Oncology
Volume 2019, Article ID 5423130, 9 pages
https://doi.org/10.1155/2019/5423130

Research Article
Knowledge, Attitudes, and Practices towards Cervical Cancer and
Screening amongst Female Healthcare Professionals: A
Cross-Sectional Study

Humariya Heena ,1 Sajid Durrani,2 Isamme AlFayyad ,1 Muhammad Riaz,3

Rabeena Tabasim,4 Gazi Parvez,5 and Amani Abu-Shaheen 1
1
Research Center, King Fahad Medical City, Riyadh, Saudi Arabia
2
Comprehensive Cancer Center, King Fahad Medical City, Riyadh, Saudi Arabia
3
Department of Statistics, University of Malakand, Chakdara, Lower Dir, Pakistan
4
Women’s Specialized Hospital, King Fahad Medical City, Riyadh, Saudi Arabia
5
Department of Anaesthesia, Sheikh Khalifa Medical City, Ajman, UAE

Correspondence should be addressed to Humariya Heena; hmunshi@kfmc.med.sa

Received 22 April 2019; Revised 13 July 2019; Accepted 28 August 2019; Published 16 October 2019

Academic Editor: Francesca De Felice

Copyright © 2019 Humariya Heena et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Background. Cervical cancer is a potentially preventable disease if appropriate screening and prophylactic strategies are employed.
However, lack of knowledge and awareness can result in underutilization of the preventive strategies. Healthcare professionals
with adequate knowledge play a huge role in influencing the beliefs and practices of the general public in a positive way. We
assessed the knowledge, attitudes, and practices of cervical cancer and screening amongst female healthcare professionals at King
Fahad Medical City (KFMC), Saudi Arabia. Methods. We conducted a cross-sectional study on female healthcare professionals at
KFMC. Data were collected using a predesigned, tested, and self-administered questionnaire. The questionnaire included specific
sections to test the participants’ knowledge, attitude, and practices related to cervical cancer and its screening. Data analysis was
done using descriptive statistics. Results. Data from 395 participants were included in the final analysis. The majority of the study
participants were nurses (n � 261, 66.1%). The mean age of the participants was 34.7 years and 239 (60.5%) participants were
married. Only 16 (4.0%) participants appeared to have good level knowledge of cervical cancer (in terms of risk factors, vul-
nerability, signs and symptoms, ways of prevention, and ways of screening) and 58 (14.7%) participants had fair level knowledge. A
total of 343 (86.8%) participants believed that Pap smear test is a useful test for the detection of cervical cancer and 103 (26.2%)
participants had undergone Pap smear testing. Conclusions. Our study population showed poor knowledge of cervical cancer as a
disease. The participants had a fair knowledge of Pap smear testing, but only a quarter of the cohort had undergone testing
themselves. This study highlights the need for formal educational programs for the healthcare workers at KFMC specifically to
improve their knowledge regarding the risk factors and early signs and symptoms of cervical cancer.

1. Background information center (2018), it is estimated that, every year,

316 women are diagnosed with cervical cancer and 158 die as
Cervical cancer is the fourth most common cancer and also a result of the disease in Saudi Arabia [3]. Several common
the fourth leading cause of cancer-related deaths in women risk factors recognized to be associated with cervical cancer
globally [1]. In Saudi Arabia, cervical cancer is the eighth worldwide include sexually transmitted diseases (mainly
most common cancer amongst women in the 45- to 59-year HPV and others human immunodeficiency virus, herpes
age group and accounts to 2.2% of all cancers [2]. According simplex virus), reproductive and sexual factors (multiple
to the fact sheet of human papillomavirus (HPV) sexual partners, early age at the first sexual intercourse, early
2 Journal of Oncology

age at first delivery, parity, and oral contraceptive pills), practices of cervical cancer screening in the general pop-
behavioral factors (smoking and obesity), and host factors ulation, especially in young girls, studies on healthcare staff
(genetic sensitivity) [4]. Abnormal vaginal bleeding, foul- have been few [23–25]. Healthcare facilities are available free
smelling vaginal discharge, and contact bleeding are rec- of cost in Saudi Arabia and it is important that these facilities
ognized as the major signs of cervical cancer, and in many are utilized well, which can help in improving the general
cases, women with cervical cancer report no symptoms. health status of the nation. Healthcare workers can play a
Almost all cervical cancers are caused by HPV and, central role in raising awareness of the general public, and
therefore, are largely preventable [5]. Over the past several therefore, their knowledge needs to be assessed and updated
decades, the incidence of cervical cancer has decreased in on a regular basis. In addition, in Middle Eastern countries,
developed countries [6, 7]. This is mainly attributed to in- in particular patients seeking medical care prefer to have
creased awareness and more effective screening and pre- women as their caregivers with several studies providing
vention strategies employed in these countries [8, 9]. In traditional and religious beliefs as the main reason. Women
addition, the HPV vaccine has contributed to a decline in the are most likely to feel comfortable to talk about their
incidence rate of cervical cancer [10]. Three types of tests are symptoms with a female only. Even female healthcare
currently available and are widely used for the screening of providers are hesitant to talk about these issues with male
cervical cancer. These include tests for HPV, cytology-based physicians.
Papanicolaou test (Pap test), and unaided visual inspection We, therefore, conducted this study to assess the
with acetic acid (VIA) [11]. However, public awareness of knowledge, attitudes, and practices towards cervical cancer
these tests especially in developing countries is limited [12]. and screening amongst female healthcare professionals at
HPV 16 and 18 are the most common subtypes of HPV King Fahad Medical City (KFMC), a tertiary hospital in
causing cervical cancer and are responsible for most of the Riyadh, Saudi Arabia.
cervical cancers worldwide [5]. The association of cervical
cancer and HPV infection implies that cervical cancer can be 2. Methods
prevented by HPV vaccination. Consequently, HPV vac-
cines have been developed [13]. In Saudi Arabia, two vac- 2.1. Study Design and Data Collection. We conducted a
cinations against HPV, bivalent vaccine (Cervarix) and cross-sectional study at KFMC in 2018. The study population
quadrivalent vaccine (Gardasil) were approved in the year included female healthcare workers with at least one year of
2010 for females between the ages of 11 and 26 years. clinical experience, including physicians, nurses, and allied
While all these developments in the prevention and health staff. The questionnaire was developed from pre-
screening of cervical cancer are taking place, it is imperative viously published studies after an in-depth literature review
that the benefits are utilized by all women including those [15–21] and then validated through experts. As per the
living in the developing countries. Having good knowledge guidelines, a committee of 2 experts each in research
and awareness will help in ensuring that the disease burden methodology, obstetrics and gynecology, and oncology
does not increase. One concerning aspect is that most pa- further confirmed the validity of the questionnaire before the
tients with cervical cancer in Saudi Arabia present at ad- pilot study. Eight questions related to signs and symptoms
vanced stages leading to adverse outcomes [14]. Moreover, it were modified, and 5 were deleted as they were either not
has been found that the cost of treating late-stage cervical applicable to healthcare workers or not related to this topic
cancer is substantially higher than that of early-stage cancer as per the expert comments. After that, pilot testing was
[15]. Screening helps in the detection of cancer at an early done on the prefinal version with 70 participants to assess
stage when it can be treated more effectively. The late the clarity of the questionnaire. Results of the pilot and the
presentation of patients with cervical cancer in Saudi Arabia current study showed that Cronbach’s alpha was >0.70.
could be due to lack of knowledge and awareness leading to The study population was stratified according to their
inadequate screening virtually nonexistent screening professions into three groups: physicians, nurses, and allied
mechanisms for early detection [14]. Moreover, the decision healthcare workers.
to undergo screening highly depends on the healthcare To ensure appropriate and equal representation from
professionals involved as well as the patient [16]. As per the each group of healthcare professionals, proportionate
results of World Health Survey Plus conducted in 2008/ sampling method according to the profession was adopted to
2009, only 7.6% of women in the 25- to 49-year age group in derive a sample with equal representation 4 : 1 : 1. 260 nurses
Saudi Arabia had a Pap smear test done, thus emphasizing (out of 2400), 65 physicians (out of 600), and 65 allied
the need to spread awareness amongst women [17]. healthcare workers (out of 700) were selected and
Prognosis can be improved if screening is embraced and approached on a random basis from each hospital/center/
widely employed. For this, it is important that the healthcare administration at KFMC. The total sample size was de-
workers are educated and well aware so that they can in- termined to be 390.
fluence the beliefs and actions of the general public. Many The study participants were randomly selected from each
studies have been conducted in other developing countries profession. A survey cover sheet explaining the study was
to gauge the knowledge and awareness about cervical cancer attached to the questionnaire and the ones who signed it
and to study the extent of utilization of the screening went to the next step of questionnaire completion. Subject
methods [12, 18–22]. In Saudi Arabia, although a number of identifiers were not used in the questionnaire, and hence,
studies have been conducted to assess the knowledge and confidentiality was maintained. A trained research assistant
Journal of Oncology 3

enrolled voluntarily willing participants who filled in the screening were described using descriptive statistics in-
questionnaire and returned it. cluding percentages, frequencies, mean, median, standard
The questionnaire was designed to include all information deviation (SD), and interquartile range (IQR). All analyses
such as sociodemographic characteristics, knowledge, atti- were conducted using the software STATA version 12.
tude, and practice of cervical cancer screening.
Participants’ knowledge of cervical cancer was assessed 3. Results
by listing questions related to risk factors, number of sexual
partners, early sexual intercourse, HPV infection, cigarette 3.1. Sociodemographic Characteristics. Of the 420 ques-
smoking, and other vulnerable factors in women. Questions tionnaires that were distributed, 395 (94%) were returned
under the five items asking about risk factors, vulnerability, and included in the analysis. The mean age (SD) of the
signs and symptoms, prevention, and ways of screening for participants was 34.7 (8.3) years. A total of 261 (66.1%)
cervical cancer were also included. respondents were nurses, 63 (16.0%) respondents were
For each item, the participants were asked to choose one physicians, and the remaining 71 (18.0%) respondents in-
of the three options: “Yes,” “No,” or “Don’t know.” cluded pharmacists, dieticians, technicians, health educa-
The scale was then dichotomized such that “Yes” was tors, physiotherapists, and therapists. About 60% of the
considered as 1 and No/Don’t know as 0. A total knowledge respondents were married. Nine (2.3%) participants re-
score for all the items was computed by adding up (maxi- ported having history of cervical cancer (Table 1).
mum score of 20). The total score was then categorized as
poor knowledge (score of 0–4), fair knowledge (score of
5–10), and good knowledge (10–20). 3.2. Participants’ Knowledge about Cervical Cancer. Many of
Participants’ attitude was assessed by asking them to rate the participants were not knowledgeable about cervical
each of the following statements on a 5-point Likert scale: (1) cancer. For example, only 8.9% of the sample knew that
carcinoma of the cervix is highly prevalent and is a leading multiple sexual partners placed a woman at risk for cervical
cause of deaths amongst all malignancies in Saudi Arabia; (2) cancer. Women older than 50 years of age are at higher risk,
any young woman including you can acquire cervical carci- yet only 8.6% of the sample had that knowledge. In advanced
noma; (3) carcinoma of the cervix cannot be transmitted from stages of cervical cancer, sign and symptoms a woman may
one person to another; (4) screening helps in prevention of experience are vaginal bleeding, foul-smelling vaginal dis-
carcinoma of the cervix; (5) screening causes no harm to the charge, and contact bleeding. However, a majority of the
client; (6) screening for cervical cancer is not expensive; and (7) participants were lacking knowledge (93%, 92%, and 87%),
if screening is free and causes no harm, will you screen? respectively. As for preventing cervical cancer, 90% of the
Respondents were asked to choose one of the following participants were unaware of the major behaviors one could
options for each of the statements listed above: “strongly do or avoid to prevent cervical cancer. Lastly, a majority of
agree,” “agree,” “neither agree nor disagree,” “disagree,” or the participants did not have knowledge about the different
“strongly disagree.” For ease of presenting results, responses ways of screening for cervical cancer (Table 2).
for “strongly agree” and “agree” and for “disagree” and
“strongly disagree” were combined. 3.3. Participants’ Attitudes towards Cervical Cancer. The
Participants’ practices were assessed by asking specific majority of participants showed disagreement for all the
questions about practices regarding cervical cancer screening. statements in this section. More than three-fourths of the
Respondents were asked whether they had heard of Pap smear participants (84.8%) disagreed with the statement “screening
test and whether they believe it is a useful tool for early de- helps in prevention of carcinoma of the cervix”. Participants’
tection of cervical cancer. They were further asked whether responses on the various statements that were designed to test
they had undergone Pap smear testing, at what interval they get their attitude towards cervical cancer are listed in Table 3.
it done, steps to be taken if any abnormality was found in Pap Overall, only 15 (3.8%) respondents agreed that they would
smear test, and reasons if they had not undergone Pap smear. have screening done if it was free and caused no harm.
The questionnaire also enquired about other details of Pap
smear testing such as the best time for doing the test, who
should do it (doctor/trained nurse), how it is done, and benefits 3.4. Practice and Knowledge of Cervical Cancer Screening.
of the test. Participants were asked whether they believe un- Although 343 (86.8%) participants believed that Pap smear
dergoing Pap smear testing is a good practice and also whether test is a useful test for detection of cervical cancer, only 103
they believe it is a painful test. Finally, they were asked whether (26.2%) participants had undergone Pap smear testing.
they were aware that HPV vaccination is done in their hospital Further, 18.7%, 43.8%, and 29.6% of the participants believed
and whether they had been vaccinated for HPV. that Pap smear test should be started at the age of 20 years, 30
The study was approved by the ethical committee at the years, and after menopause, respectively. Sixty-three percent
KFMC, and informed consent was obtained from each of the respondents agreed that the best time for a Pap smear
participant before enrolment. test is a week after period, and 76.2% believed that Pap smear
testing should be done by a doctor. Also, 78.9% of the re-
spondents agreed that further tests should be done if any
2.2. Statistical Analysis. Demographic characteristics, abnormality is detected in Pap smear test. Only 56 (14.2%)
knowledge, attitude, and practice of cervical cancer respondents were aware that HPV vaccination is available at
4 Journal of Oncology

Table 1: Participants’ sociodemographic characteristics. KFMC and 22 (5.6%) had been vaccinated for HPV. Table 4
Mean (SD)/median
presents the results of participants’ responses to questions on
Variables knowledge and practice of cervical cancer screening.
(IQR)a
Age∗ 34.7 (8.3)
Table 5 shows the relation of the total score for
Experience in years∗ 10 (6–16) knowledge about cervical cancer (categorical) with de-
Age at marriage∗ (n � 252) 26.2 (4.4) mographic variables.
Number of The total scale score was significantly negatively corre-
2 (1–3) lated with age (p value � 0.002) and the total number of years
pregnancies∗ (n � 252)
Designation n (%)b of experience (p value � 0.004). When we used logistic re-
Physician 63 (16.0) gression with binary variable (fair-good knowledge � 1 and
Nurse 261 (66.1) poor � 0) as a dependent variable and categorical age (≤30
Pharmacist 5 (1.3) years vs. >30 years) as explanatory, younger age was sig-
Dietician 3 (0.8) nificantly associated with the higher odds of having fair to
Technician 23 (5.8)
good knowledge odds ratios (OR � 2.22, 95% CI (1.31–3.78).
Health educator 1 (0.3)
Physiotherapists 7 (1.8)
However, when categorized, the years of experience (<10
Therapist 21 (5.3) years vs. ≥10 years) did not stand significant (Table 5).
Others 11 (2.8)
Hospital/center/department∗ 4. Discussion
Comprehensive Cancer Center 16 (4.1)
National Neurosciences Institute 9 (2.3) Progress in the understanding of cervical cancer has helped
King Salman Heart Center 19 (4.8) recognize its preventable nature [5]. It is well established that
Obesity Endocrine and Metabolic HPV vaccination and adequate screening can reduce the
1 (0.3)
Center burden of the disease to a great extent [6, 7]. For effective
Women’s Specialized Hospital 49 (12.4) screening and prophylaxis, it is of utmost importance to
Children’s Specialized Hospital 135 (34.2) understand the knowledge, perceptions, and beliefs of the
Rehabilitation Hospital 33 (8.4) population especially that of the healthcare staff as they
Main Hospital 101 (25.6)
constitute an important source of propagation of health-
Others 28 (7.1)
Level of education∗
related information. Many studies conducted in the de-
High school or diploma 69 (17.5) veloping countries have shed light on the level of un-
Bachelor 272 (68.9) derstanding and knowledge of the population, which could
Master or PhD 52 (13.2) provide useful information to the healthcare systems to
Marital status∗ develop appropriate educational strategies [19–21].
Single 143 (36.2) Our cohort scored very poorly on the knowledge score,
Married 239 (60.5) which is quite alarming as basic level of knowledge about
Divorced 11 (2.8) common diseases is expected from the healthcare staff.
Widow 1 (0.3) Adequate knowledge is an important determinant of positive
Single marriage (monogamy)∗ (n � 252) 223 (88.5) attitude and because our study population did not have the
Number of children (parity, n � 252)∗
knowledge, their attitude and beliefs were also concerning.
0 41 (16.3)
1–3 166 (65.9) On the other hand, participants’ knowledge about the
>3 31 (12.3) screening of cervical cancer was fairly good. Most re-
Number of abortions∗ (n � 252) spondents believed that Pap smear is a useful tool for early
0 157 (62.3) detection of cervical cancer. They also seemed to have a fair
1–2 63 (25.0) knowledge about certain aspects of Pap smear testing such as
>2 10 (4.0) timing of doing Pap smear, action to be taken if the Pap test
One or more stillbirths∗ (n � 252) 18 (7.1) results are positive, and so on.
Any history of cervical cancer∗ 9 (2.3) In a study conducted on medical students in Al-Ahsa,
First-degree relatives’ history of about fifty percent of the study participants were aware of
15 (3.8)
cervical cancer∗
the early signs and symptoms and risk factors of cervical
Second-degree relatives or friend
with history of cervical∗
12 (3.0) cancer [26]. The better knowledge of these students com-
a
pared to our cohort can be explained by the fact that these
Mean (standard deviation (SD))/median (interquartile range (IQR)).
b
Frequency (percentage). ∗ Data are missing in participants’ age
students, especially those in the final year, must have been
(n � 30), years of experience (24), age at marriage (163), number of taught about cervical cancer as a part of their curriculum
pregnancies (150), hospital/center/department (4), level of education recently and therefore were more informed about the dis-
(2), marital status (1), single marriage (163), number of children (152), ease. This implies is that medical students are not educated
number of abortions (163), one or more stillbirths (164), history of about cervical cancer in any depth. Therefore, they are most
cervical cancer (13), first-degree relatives’ history of cervical cancer
(19), and second-degree relatives or friend’s history of cervical (31). In likely not informed prior to practice. It reflects that there are
the calculation of percentages (%), the denominators include missing no continuing medical education activities regarding cer-
observations. vical cancer screening and prevention for healthcare
Journal of Oncology 5

Table 2: Participants’ knowledge about cervical cancer.

Items of the knowledge scale for cervical cancer Frequency (%)a 95% CIb
Risk factors
R1: multiple sexual partners∗ 35 (8.9) 6.2–12.1
R2: early sexual intercourse∗ 57 (14.4) 11.1–18.3
R3: HPV infection (human papillomavirus)∗ 38 (9.6) 6.9–13.0
R4: infection with the human immunodeficiency
54 (13.7) 10.4–17.5
virus (HIV)∗
R5: cigarette smoking∗ 51 (12.9) 9.8–16.6
R6: ever used contraceptive methods∗ 53 (13.4) 10.2–17.2
Vulnerability
V1: women age >50 years∗ 34 (8.6) 6.0–11.8
V2: reproductive age∗ 55 (13.9) 10.7–17.7
V3: both of the above∗ 62 (15.7) 12.3–19.7
Sign and symptoms
S1: vaginal bleeding∗ 27 (6.8) 4.6–9.8
S2: foul-smelling vaginal discharge∗ 29 (7.3) 5.0–10.4
S3: contact bleeding∗ 48 (12.2) 9.1–15.8
Prevention
P1: avoiding multiple sexual partners∗ 30 (7.6) 5.2–10.7
P2: avoiding early sexual intercourse∗ 49 (12.4) 9.3–16.1
P3: screening and treatment∗ 11 (2.8) 1.4–4.9
P4: avoid/quit cigarette smoking∗ 39 (9.9) 7.1–13.2
P5: all of the above∗ 39 (9.9) 7.1–13.2
What are the ways of screening
WS1: Pap smear∗ 17 (4.3) 2.5–6.8
WS2: visual inspection of cervix∗ 25 (6.3) 4.1–9.2
WS3: human papillomavirus DNA testing∗ 42 (10.6) 7.8–14.1
WS4: liquid-based cytology∗ 75 (19.0) 15.2–23.2
WS4: there is no way of screening∗ 31 (7.9) 5.4–11.0
Median (IQR) total score for the knowledge scaleϮ 1 (0–4)
Level of knowledge based on the total score
Poor (score of 0–4) 311 (80.8) 76.5–84.5
Fair (score of 5–10) 58 (15.0) 11.6–18.8
Good (score of 11–20) 16 (4.2) 2.5–6.8
a
Frequencies and percentage (%) for the “Yes” responses; percentages are computed with missing observations included in the denominator. b95% confidence
intervals in column 3 for the percentages (%) in column 2. ϮResponses to each item in column 1 were recoded as Yes � 1 and No or Don’t know � 0, and total
score (0–20) was computed, and median total score (interquartile range (IQR)) is presented in the table. ∗ Data are missing in R1 (for 22 participants), R2 (24),
R3 (20), R4 (41), R5 (29), and R6 (51); V1 (39), V2 (50), and V3 (77); S1 (14), S2 (19), and S3 (24); P1 (23), P2 (29), P3 (19), P5 (29), and P6 (67); WS1 (20), WS2
(35), WS3 (67), WS4 (72), and WS5 (73).

Table 3: Participants’ attitudes towards cervical cancer.

Statements describing attitudes of the participants
Agree, n (%) Neither agree nor disagree, n (%) Disagree, n (%)
towards cervical cancer
A1: carcinoma of the cervix is highly prevalent and is
a leading cause of deaths amongst all malignancies in 52 (13.2) 124 (31.4) 210 (53.2)
Saudi Arabia∗
A2: any young woman including you can acquire
29 (7.3) 48 (12.2) 309 (78.2)
cervical carcinoma∗
A3: carcinoma of the cervix cannot be transmitted
79 (20.0) 39 (9.9) 265 (67.1)
from one person to another∗
A4: screening helps in prevention of carcinoma of the
18 (4.6) 32 (8.1) 335 (84.8)
cervix∗
A5: screening causes no harm to the client∗ 36 (9.1) 41 (10.4) 309 (78.2)
A6: screening for cervical cancer is not expensive∗ 51 (12.9) 108 (27.3) 225 (57.0)
A7: if screening is free and causes no harm, will you
15 (3.8) 29 (7.3) 342 (86.6)
screen?∗
∗
n (%): frequencies (percentage) of participants; percentages are computed with missing observations included in the denominator. Data are missing in A1
(for 9 participants), A2 (9), A3 (12), A3 (10), A5 (9), A6 (11), and A6 (9).
6 Journal of Oncology

Table 4: Practice and knowledge of cervical cancer screening.

Statements for assessing knowledge and practice of
Frequency (%)a 95% CIb
cervical cancer screening
KP1: yes—I have heard of Pap smear test for CCS∗ 335 (84.8) 81.3–88.2
KP2: it is a useful tool for early detection of cervical
343 (86.8) 83.1–90.0
cancer∗
KP3: age at which Pap smear test be started∗
From birth 1 (0.3) 0.01–1.4
From puberty 23 (5.8) 3.7–8.6
From 20 years 74 (18.7) 15.0–22.9
From 30 years 173 (43.8) 38.8–48.8
After menopause 117 (29.6) 25.2–34.4
KP4: yes—I have undergone Pap smear test∗ 103 (26.2) 21.9–30.9
KP5: if yes to above, interval for Pap smear test∗
Monthly 6 (5.4) 2.0–11.4
Yearly 76 (68.5) 59.0–77.0
After menopause 3 (2.7) 0.5–7.7
Not sure 26 (23.4) 15.9–32.4
KP6: reasons if the test is not done∗
I see no reason for the test 116 (48.5) 42.0–55.0
I am afraid of the procedure 41 (17.2) 12.6–22.5
I am afraid of the bad results 8 (3.4) 1.5–6.5
I do not know whom to consult for undergoing this
27 (11.3) 7.6–16.0
test
Others (including multiple of the above) 47 (19.7) 14.8–25.2
KP7: best time for doing Pap smear test∗
During menstrual flow 12 (3.0) 1.6–5.2
A week after period 249 (63.0) 58.1–67.8
During pregnancy 2 (0.5) 0.06–1.8
During breastfeeding 1 (0.3) 0.0–1.4
Not sure 119 (30.1) 26.0–34.9
KP8: Pap smear test should be done by∗
Doctor 301 (76.2) 71.7–80.3
Trained nurse 29 (7.3) 5.0–10.3
Not sure 29 (7.3) 5.0–10.3
Others (including the 1st two) 25 (6.3) 4.1–9.2
KP9: abnormality in Pap smear test, what should be
done?∗
Leave it to God and pray 2 (0.5) 0.0–1.8
Do some lab tests 312 (78.9) 74.6–82.9
Not sure 40 (10.1) 7.3–13.5
Others 31 (6.3) 4.19.2
KP10: benefits of Pap smear test∗
Early detection of cervical cancer 175 (44.3) 39.3–49.4
Detection of any early abnormal changes in the
132 (33.4) 28.8–38.3
cervix
Not sure 20 (5.1) 3.1–7.7
Above two 59 (14.9) 11.6–18.8
KP11: Pap smear test is painful∗ 156 (39.5) 34.6–44.5
KP12: undergoing Pap smear test is a good practice∗ 324 (82.0) 77.9–85.6
KP13: Pap smear test is done using∗
Transvaginal ultrasound 40 (10.1) 7.3–13.5
Vaginal brushing 224 (56.7) 51.7–61.7
Not sure 89 (22.5) 18.5–27.0
Others 33 (8.4) 5.8–11.5
KP14: human papillomavirus vaccination is available
56 (14.2) 10.9–18.1
in our institution∗
KP15: I have been vaccinated for human
22 (5.6) 3.5–8.3
papillomavirus∗
a
Frequencies and percentage (%) of participants’ responses; percentages are computed with missing observations included in the denominator. b95%
confidence intervals in column 3 for the percentages (%) in column 2. ∗ Data are missing in KP1 (for 2 participants), KP2 (4), KP3 (7), KP4 (2), KP5 (not
applicable or missing: 284), KP6 (not applicable or missing: 156), KP6 (12), KP7 (11), KP9 (10), KP10 (9), KP11 (11), KP12 (9), KP13 (48), and KP14 (47).
Journal of Oncology 7

Table 5: Relation of the total score for knowledge about cervical cancer (categoricala) with demographic variables.
Poor knowledge (score: Fair knowledge (score: Good knowledge (score:
p
Sociodemographic variables 0–4) 5–10) 11–20)
values
Median (IQR) Median (IQR) Median (IQR)
Age (≤30 years vs. >30 years) 34 (30–41) 29 (25–37) 35 (28–37.5) 0.002
Age at marriage 26.5 (24–28) 27 (24–29) 26.5 (25.5–28) 0.701
Total experience in years (<10 years vs. ≥10
11 (7–16) 8 (1–13) 10.5 (4–14.5) 0.004
years)
n (%) n (%) n (%)
Level of education
High school or diploma 56 (18.1) 8 (13.8) 4 (25.0) 0.485
Bachelor 216 (69.9) 40 (69.0) 9 (56.3)
Master or PhD 37 (12.0) 10 (17.2) 3 (18.8)
Designation/profession
Nurses 218 (70.1) 31 (53.5) 8 (50.0) 0.030
Physicians 48 (15.4) 11 (19.0) 3 (18.8)
Others 45 (14.5) 16 (27.6) 5 (31.3)
Hospital/center/department
Others 126 (40.9) 20 (34.5) 8 (53.3) 0.139
CSH 104 (33.8) 27 (46.6) 2 (13.3)
Main Hospital 78 (25.3) 11 (19.0) 5 (33.3)
a
Knowledge of cervical cancer could not be determined for 10 participants due to missing data for some of the responses.

professionals in the region. Moreover, there is a low in- is presently offered to selected individuals including women
cidence of cervical cancer in Saudi Arabia due to which the confirmed at risk for HPV infection or who voluntarily want
healthcare professionals come across few cases with cervical to be vaccinated [32]. These vaccines are available in Saudi
cancer, and therefore, they have inadequate knowledge re- Arabia in select hospitals. KFMC is one such hospital and
garding HPV vaccine and other prevention modes [27]. This young female staff should take advantage of this facility and
highlights the fact that continued medical education is protect themselves from HPV infection. From the results of
imperative to help the healthcare staff to keep abreast of the our study, it appears that most of our staff are not aware that
facts about important diseases as well as to keep them this vaccine is available within KFMC. This calls for an
updated with the newer developments related to healthcare. urgent need to plan strategies to educate the staff not only on
When formal screening programs are not in place, the benefits and need of HPV vaccination but also about its
cervical screening is mostly “opportunistic,” which means availability within the KFMC facility.
women attending the clinics for other ailments are directed A study was conducted in Riyadh, Saudi Arabia, to
by the healthcare workers for cervical cancer screening. This examine whether the educational program had any effect on
is mostly done by staff in the gynecological department; female healthcare students in terms of their knowledge
however, if healthcare workers in other specialties also start regarding screening and prevention of cervical cancer. The
referring eligible patients, the number of patients un- results were promising with all scores improving signifi-
dergoing cervical cancer screening will greatly increase cantly after the intervention in the form of educational
[23, 28]. program. This study provides further insight into the ne-
Most women in our cohort were young and married cessity and importance of educational activities, which could
making them most likely sexually active. Although multiple be in the form of lectures using audiovisual aids [24].
sexual partners are a risk factor for cervical cancer, we did Our study has several limitations. Firstly, it was con-
not include that personal question to the participants, be- ducted only in one center, and therefore, the results cannot
lieving it to be offensive to the culture in Saudi Arabia. It is be generalized to the healthcare workers at other institutions
highly recommended to have Pap smear done in women in Saudi Arabia. Secondly, our sample was composed of a
above 21 years of age [29]. Also, HPV vaccine can be taken heterogeneous group of healthcare workers including
by women until the age of 26 years [30]. Gardasil (quad- physicians, nurses, and allied healthcare workers in various
rivalent vaccine effective against HPV types 6, 11, 16, and 18) specialties which may have led to varied knowledge, attitude,
and Cervarix (bivalent vaccine effective against HPV types and practices towards the screening. It is sad that healthcare
16 and 18) are the two vaccines approved by the US FDA in workers especially nurses and physicians lacked the
2006 and 2009, respectively [30, 31]. These are widely used in knowledge they should have had from their formal
western countries, and their use should be encouraged in education.
developing countries. These vaccines were approved in Saudi The study results imply that if women, irrespective of
Arabia in the year 2010 for females between the ages of 11 their profession, do not receive education to increase their
and 26 years [13]. Vaccination for HPV could not be in- functional knowledge, understanding, and acceptance of
cluded in Saudi’s national vaccination programs viewing the routine cervical cancer screening, then they may not be able
low incidence and higher cost for the health system. Thus, it to promote behavior change in themselves, in their patients,
8 Journal of Oncology

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The authors declare that they have no conflicts of interest. to low-income women under the Medicaid expansion for
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