Elgzar et al.

Intention and self-efficacy for pap smear screening

ORIGINAL RESEARCH ARTICLE

Intention and self-efficacy for pap smear screening and Human

Papilloma Virus vaccination among Saudi women at Najran city,
KSA
DOI: 10.29063/ajrh2022/v26i7s.7

Wafaa T. Elgzar1, Mohammed A. Alshahrani2*, Mohammed H. Nahari2, DaifAllah D. Al-

Thubaity1, Heba A. Ibrahim1, Samiha H. Sayed3,4, Hanan A. El Sayed5,6
Department of Maternity and Childhood Nursing, Nursing college, Najran University, Saudi Arabia1; Department of
Clinical Laboratory Sciences, Najran University Najran, Saudi Arabia2; Department of Community Health Nursing,
Faculty of Nursing, Damanhour University, Egypt3; Department of Public Health, College of Health Sciences, Saudi
Electronic University, Saudi Arabia4; Applied College, Tabuk University, Saudi Arabia5; Department of Community
Health Nursing, Faculty of Nursing, Benha University, Egypt6

*For Correspondence: Email: maalshahrani@nu.edu.sa; Phone: +66551755558

Abstract
Exploring the women's intention of the core self-directed behaviors for cervical cancer prevention and their confident abilities for
engagement is of utmost importance for targeted intervention development. This study investigates the Saudi women's intention
and self-efficacy for Pap Smear Screening and HPV Vaccination in Najran city, KSA. It was a descriptive cross-sectional study
incorporating a convenient sample of 1085 Saudi women through a social media-based four-part questionnaire: Basic Data and
Reproductive Health History, Pap Smear Intention Scale, HPV vaccination intention scale, Self-Efficacy Scale for Pap smear
testing, and HPV vaccination. The results indicated that 59.5% of the study participants had a low intention for Pap testing, while
62.5% of them had a high intention to receive the HPV vaccine, and the self-efficacy for both was high among 57.0% of them.
Binary logistic regression showed higher odds for Pap testing intention among older women with enough family income and those
with no history of Pap testing and higher gravidity and parity. Rural resident women and those having no family history of CC have
Lower odds for HPV vaccination intention. Women of reproductive age and those with high gravidity and parity have higher odds.
Self-efficacy has lower odds among divorced, rural resident women and those with no history of Pap testing or HPV vaccine;
however, women with longer marriage duration and higher gravidity and parity had higher odds. Hence, there is an apparent high
intention for HPV vaccination with a low intention for Pap testing among Saudi women in Najran despite having a higher self-
efficacy. These necessitate establishing consolidated efforts for awareness-raising and advocacy programs to prevent CC. (Afr J
Reprod Health 2022; 26[7s]: 61-73).

Keywords: Cervical cancer, intention, self-efficacy, pap smear, HPV vaccine

Résumé
Explorer l'intention des femmes concernant les comportements autodirigés de base pour la prévention du cancer du col de l'utérus
et leurs capacités confiantes d'engagement est de la plus haute importance pour le développement d'interventions ciblées. Cette
étude examine l'intention et l'auto-efficacité des femmes saoudiennes pour le dépistage par frottis de Pap et la vaccination contre
le VPH dans la ville de Najran, en Arabie saoudite. Il s'agissait d'une étude transversale descriptive incorporant un échantillon
pratique de 1085 femmes saoudiennes par le biais d'un questionnaire en quatre parties basé sur les médias sociaux: données de base
et antécédents de santé reproductive, échelle d'intention de frottis Pap, échelle d'intention de vaccination contre le VPH, échelle
d'auto-efficacité pour Pap les tests de frottis et la vaccination contre le VPH. Les résultats ont indiqué que 59,5 % des participants
à l'étude avaient une faible intention de subir un test Pap, tandis que 62,5 % d'entre eux avaient une forte intention de recevoir le
vaccin contre le VPH, et l'auto-efficacité pour les deux était élevée chez 57,0 % d'entre eux. La régression logistique binaire a
montré des probabilités plus élevées d'intention de test Pap chez les femmes âgées ayant un revenu familial suffisant et celles sans
antécédents de test Pap et ayant une gravidité et une parité plus élevées. Les femmes qui résident en milieu rural et celles qui n'ont
pas d'antécédents familiaux de CC ont des probabilités plus faibles d'avoir l'intention de se faire vacciner contre le VPH. Les
femmes en âge de procréer et celles dont la gravidité et la parité sont élevées ont des chances plus élevées. L'auto-efficacité a des
probabilités plus faibles chez les femmes divorcées résidant en milieu rural et chez celles qui n'ont pas d'antécédents de test Pap ou
de vaccin contre le VPH; cependant, les femmes avec une durée de mariage plus longue et une gravidité et une parité plus élevées
avaient des chances plus élevées. Par conséquent, il y a une intention élevée apparente pour la vaccination contre le VPH avec une

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Elgzar et al. Intention and self-efficacy for pap smear screening

faible intention pour le test Pap chez les femmes saoudiennes à Najran malgré une auto-efficacité plus élevée. Celles-ci nécessitent
la mise en place d'efforts consolidés pour des programmes de sensibilisation et de plaidoyer afin de prévenir le CC. (Afr J Reprod
Health 2022; 26[7s]: 61-73).

Mots-clés: Cancer du col de l'utérus, intention, auto-efficacité, test de pap, vaccin contre le VPH

Introduction women with a history of genital warts, sexually

transmitted infection, poor menstrual hygienic
Cervical Cancer (CC) is an overarching public practices, low education, rural residence, and lack
health problem that roughly every woman (aged at of a health services accessibility. Once diagnosed,
least 30 years) is vulnerable to CC. It is the highest the early stage of CC is generally asymptomatic;
frequent reproductive system cancer with however, the more-advanced cases usually
associated mortality. Globally in 2020, the World complain of vaginal bleeding (post sexual
Health Organization (WHO) appraised CC as the intercourse or during the menstrual cycle or after
fourth most highly frequent type of cancer, with menopause), foul odor vaginal discharge (watery or
604.000 incident cases and 342.000 deaths. bloody), and pelvic pain or painful sex3,5.
Specifically, the low- and average-income Fortunately, CC is the most preventable
countries had the most cases (90%) and related and curable type of cancer through an inclusive and
deaths. Approximately all CC cases (99%) were multidisciplinary approach throughout the women's
attributed to a sexually transmitted infection with life course. This approach was recommended in
the Human Papillomavirus (HPV). It is a shared 2020 by the World Health Assembly as a global
infection in both sexes who are sexually active; they strategy to eliminate CC. Aside from the
may get HPV infection once in their lives or might importance of health education about its risk factors
be infected recurrently. Even though HPV is a among the growing girls and women either at a
mostly asymptomatic and self-limited infection, if health facility, school, or community level,
it persists for a long time, this increases the risk for vaccination and screening have a chief role in CC
the progression of precancerous lesions to invasive prevention. The Papanicolaou smear (Pap smear)
CC among women. Nearly half of CC cases are screening tool can discover cervical cytological
attached to two major HPV species (HPV-16 and abnormalities3,6. The United States Preventive
18)1-3. Services Task Force (USPSTF) recommends Pap
Saudi Arabia's information center on smear screening every three years for women (21-
Human Papillomavirus (HPV) and cancer by the 65 years). For those aged 30-65 years, both (Pap
end of 2021 highlighted that CC is the eighth most smear and HPV tests) should be carried out every
frequently encountered cancer and the seventh five years7. The HPV vaccine proved to protect
leading cause of death among Saudi women. It also against the main evident cause of CC. The WHO
confirmed that all Saudi women aged 15 years or recommends this vaccine for girls (9 -14 years)
more (10.3 million) are at risk for CC, with 358 before initiating sexual activity6.
annual incidence cases and 179 deaths. HPV-linked In Saudi Arabia, there is no universal CC
data is limited in Saudi Arabia, but in the Asian screening program which can probably explain why
region, nearly 2.5% of reproductive-age women 43.0% of cases are diagnosed at late stages (III and
were infected with HPV-16 and 18 at a given time. IV) compared to a lower trend (25.0%) in British
In addition, overall, 72.4% of the invasive CC cases Colombia, which has an operative program for CC
are attributed to both types of HPV4. screening. Besides, the low awareness and
Evidence showed many other risk factors compliance with CC screening recommendations
for CC, such as smoking, early marriage (before 18 and the limited availability of HPV immunization
years), high parity number, and having many sexual in Saudi Arabia for those aged 9 to 26 years.
partners. The latter is common in Saudi culture and However, it is recently added to the immunization
the Islamic religion, legitimizing multiple schedule of girls and boys (9–12 years old). These
marriages for men. In this way, he can transmit the can aid in the future elimination of cases of both CC
infection to his wives. A recent case-control study and penile cancer8-10.
in 2019 by Kashyap et al. added other risk factors Thus, the core of CC prevention is the
for CC where it showed high odds for CC among prevention and early detection through screening

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Elgzar et al. Intention and self-efficacy for pap smear screening

and HPV vaccination which merely rely on the - What is the level of self-efficacy for Pap
women’s active participation and self-motivation to testing and HPV vaccinations among Saudi
engage in such preventive health behaviors4,10. In women in Najran city?
this regard, the role of intention and self-efficacy - What are the associated factors with the self-
was enlightened, which have proved as the prime efficacy and intention for Pap testing and
theoretical constructs in forecasting health HPV vaccinations?
behaviors. Distinctly, many theoretical perspectives
have explained the important role of the intention in Study design and setting
screening behaviors coupled with an individual's
self-efficacy to foster the change of this intention to This descriptive cross-sectional research study was
actual behavior, such as the social cognitive theory, accomplished in Najran city, KSA, as the biggest
health belief model, theory of reasoned action city in the Najran region with a great number of
which extended to a theory of planned behavior, women (20-60 years), representing one-half of the
and the integrated behavioral model11-13. total females and nearly one-quarter of the total
The intention is considered the culmination population in the region18.
of the individual's decision-making process. It
signals the end up of the individual’s self- Study respondents and sample size
deliberation about certain behavior. It captures the estimation
self-developed performance standard, the
A convenient sample of 1085 Saudi women was
commitment to this standard, and the devoted time
enrolled who were Saudi women (>18 years),
and effort for this action14. Given the centrality of
resided in Najran city, able to read and write,
the intention construct to several health behavior
mentally alert, and welcomed the participation in
models, it can be affected by various social,
the study. The data was compiled using a social
economic, cultural, and personal factors. One of the
media-based survey created using the Survey
most influencing personal forces on the intention is
Monkey program. A link was created and shared via
the individual self-efficacy13. It explores the
various social media platforms such as Twitter,
individual's perceived confidence in his ability for
Telegram, Facebook, WhatsApp, and Instagram.
successful behavioral conduction besides the ability
The sample size was estimated using the
to control the probable faced personal or
Epi-info sample size calculator based on these
environmental barriers. Recent evidence indicates
parameters: total population size = 136090;
that various complex sociodemographic, cultural,
anticipated frequency (50%), a margin of error
and personal factors may influence the women’s
(5%), and 95.0% confidence interval. A minimum
decision-making process for engaging in CC
required sample size of 1075 participants has
screening and vaccination by influencing their
resulted. Finally, 1150 women have been included
attitudes, intention, and self-efficacy. This is mainly
in the study to compensate for possible exclusion
evident through the discovered considerably overall
due to incongruence with inclusion criteria.
low rate of CC screening service utilization that is
varied between countries by many recent
Questionnaire development
studies15-17. Thus, the present study intended to
investigate Saudi women's intention and self- It encompassed four parts as follows:
efficacy for Pap Smear Screening and HPV • Basic Data and Reproductive Health History:
Vaccination and their associated factors in Najran age, residence, education, family history of
city, KSA. cancer, existing contraceptives use, history of
HPV vaccine or Pap smear, marriage age and
Methods
duration, gravidity, parity, and self-reported
Research questions family income as enough or not enough.
- What are the intention levels for Pap smear • Pap Smear Intention Scale: the investigators
screening and HPV vaccinations among developed it after reviewing the related
Saudi women in Najran city? literature. The women were asked about their

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Elgzar et al. Intention and self-efficacy for pap smear screening

future Pap testing intentions using four items on Data collection

five-point Likert scales from (1) extremely
likely to (5) extremely likely. The composite The weblink of the questionnaire was released on a
score (5-20) was categorized as low (<60%), variety of social media platforms (Twitter,
and high (> 60%) intention19,20. Facebook, WhatsApp, Telegram, and Instagram).
• The investigators designed the HPV The data was collected over nearly four months
vaccination intention scale after reviewing the (from October 2021 till the end of January 2022).
relevant literature. The authors inquired the The average filling time for the questionnaire, as
women to rate their future HPV vaccination recorded by Survey Monkey, was10-15 minutes.
intention using five statements on a 5-point-
Likert scale from (1) extremely unlikely to (5) Data analysis
extremely likely. The total score was calculated
by summing items and ranged from (5-25). The The Statistical Package for Social Science [SPSS]
women were considered to have low (1-15) and version 23 (IBM Corp., Armonk, N.Y., USA) was
high (16-25) intentions based on their total deployed for data analysis. The authors summarized
score21. the study variables using frequency, Percent,
Arithmetic Mean, and Standard Deviation. Binary
• Self-Efficacy Scale for Pap Smear testing and logistic regression was utilized to assess the odds of
HPV vaccination: it was adopted from Stout et correlation with intention and self-efficacy. An
al., (2020)22 and Fernandez et al., (2009)23, adjusted odds ratio (AOR) with 95% confidence
where women were asked to rate their sureness intervals (CI) and a P-value of less than 0.05 were
in their ability to perform Pap testing (8 items) deemed to have a statistical significance of
or HPV vaccination (3 items). It was translated association with women's intention and self-
into the Arabic language by the investigators. A efficacy.
three-point Likert scale was used (1=unsure,
2=undecided, 3= sure). The total score (11-33)
was calculated by summing items and leveled
Results
into low (11-22) and high (23-33) self-efficacy
Table 1 shows that most of the study participants
based on the women's scores. were married (91.7%) and urban residents (93.9%).
Besides, 65.3% of the study participants are highly
Questionnaire validity and reliability
educated, and 85.7% reported enough monthly
The instrument was examined for its content, face, income. History of gynecologic operation, genital
and construct validity by six experts in the field as infection, contraceptive use, and family history of
a jury. It exhibited a good Content Validity Index cervical cancer were reported by 17.9%, 47.6%,
(CVI=0.85) for items relevance. The investigator 74.6%, and 3.3% of the study participants,
executed the proposed modifications to confirm the respectively. Almost all the study participants did
content's ease, relevance, and coherence. Reliability not receive the HPV vaccine (99.0%) or the Pap
was guaranteed by the Alpha Cronbach test that smear test (98.0%). The table also shows the means
proved homogeneity of the items for all scales with of the study participants' age (37.79), age at
a satisfactory internal consistency score: Pap smear marriage (23.03), marriage duration (15.17),
intention (α=0.85), HPV vaccination intention gravidity (4.34), and parity (3.59).
(α=0.80), and self-efficacy (α=0.86). Table 2 reveals that 38.3% of the study
participants can discuss Pap smears with their
Pilot study healthcare providers, and 43.9% are sure they can
stick to pap smear appointments. Besides, 34.2%
It was performed on 100 Saudi women (not are sure that they can keep having a Pap test even if
incorporated in the study sample) to assure the they go to a new health office, and 43.0% can ask
questionnaire's clarity, easiness, and applicability. for a referral for Pap testing from their primary
The required minor modifications were healthcare providers. Self-efficacy related to the
accomplished to finalize the questionnaire. continuity of regular Pap testing, even if it would be
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Elgzar et al. Intention and self-efficacy for pap smear screening

Table 1: Participants' basic data and reproductive health vaccination among 62.5% of them. Self-efficacy for
history (n= 1085) Pap testing and HPV vaccination was high among
Basic data 57.0% of the study participants.
N % Table 3 shows that age, monthly income,
(1085) history of Pap smear screening, gravidity, and
Marital status
995 91.7
parity can predict women's Pap smear screening
Married
Divorced 68 6.3 intention. Older women with enough family income
Widow 22 2.0 have a higher probability of performing a Pap smear
Residence test when taking a young woman with little monthly
Rural 66 6.1 income as a reference [AOR=1.499(1.101-2.041),
Urban 1019 93.9 P=0.010], and [AOR=1.669(1.090-2.557),
Education
Secondary education 377 34.7
P=0.018], respectively. Having no history of Pap
University/ postgraduate 708 65.3
smear tests increases the probability of future
Self-reported monthly income screening compared with women with previous Pap
Not enough 155 14.3 smear results. [AOR=0.287(0.049- 0.984),
Enough 930 85.7 P=0.038]. High gravidity and parity increase the
History of gynecologic operations probability of performing Pap smear screening
Yes 194 17.9
compared to nulligravida and nulliparous women
No 891 82.1
History of genital infection
[AOR=1.745(1.054-2.890), P=0.030], [AOR
Yes 517 47.6 =2.620 (1.061-6.469), P=0.037], respectively.
No 568 52.4 Residence, family history of CC, age at
History of contraceptive use marriage, gravidity, and parity are positively
Yes 809 74.6 associated with HPV vaccination intention. Being
No 276 25.4
rural resident and having no family history of CC
Family history of cervical cancer
Yes 36 3.3 have lower intention to receive HPV
No 1049 96.7 [AOR=0.536(0.307-0.936), P=0.028],
History of HPV vaccination [AOR=0.689(0.374-0.972), P=0.002]. The positive
Yes 11 1.0 predictors for HPV vaccination intention are high
No 1074 99.0 gravidity [AOR=5.812(1.965-12.233), P=0.019],
History of Pap smear screening parity [AOR=4.812(1.635-14.163), P=0.004], and
Yes 22 2.0
being in reproductive age [AOR=1.322(0.979-
No 1063 98.0
Mean age in years (SD) 37.79(7.41) 1.791), P=0.039].
Marriage age mean in years (SD) 23.03(4.95) The significant predictors for high self-
Marriage duration mean in years 15.17(9.73) efficacy are marital status, residence, history of Pap
(SD) smear/HPV, marriage duration, gravidity, and
Gravidity mean (SD) 4.34(2.89)
3.59(2.35)
parity (p˂0.05). Being divorced decreases the
Parity means (SD)
probability of having high self-efficacy when
painful, was assured by 40.5% and 38.6, taking a married woman as a reference
respectively. In addition, 43.8% are sure they will [AOR=0.575 (0.333-0.993), P=0.047]. Besides,
perform a Pap smear even if friends discourage rural residents have a lower probability of having
them, and 46.5% are ready to pay for it. Regarding high self-efficacy when compared to urban
the HPV vaccination, the study participants are sure residents [AOR=0.489(0.274-0.872), P=0.015].
that they will get HPV vaccination even if it is Having no history of Pap testing or HPV vaccine
expensive (46.0%) or the shot hurts a little (44.0%), decreased the chance of high self-efficacy
and 38.7% of them are sure that they can find time [AOR=0.187(0.039- 0.884), P=0.034]. Longer
for vaccine appointments. marriage duration increased the probability of
Figure 1 illustrates that 59.5% of the study having higher self-efficacy [AOR=2.309(1.421-
participants have a low intention for Pap smear 3.751), P=0.001]. Increasing the gravidity and
screening compared to a high intention for HPV parity numbers are positive predictors of high self-

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 Elgzar et al. Intention and self-efficacy for pap smear screening

Table 2: Self-Efficacy of Pap Smear screening and HPV Vaccination among the study participants

Sure Undecided Unsure

Questions: How sure are you that you can……?
No(%) No(%) No(%)
Pap Smear Self-Efficacy
Discuss having a Pap test with your healthcare provider even if (s)he does not bring it up? 416(38.3) 513(47.3) 156(14.4)
Schedule a Pap test appointment and keep it? 476(43.9) 409(37.7) 200(18.4)
Keep having a Pap test even if you had to go to a new office to get one? 371(34.2) 450(41.5) 264(24.3)
Ask your primary care physician for a referral to get a Pap test? 466(43.0) 388(35.8) 231(21.2)
Go to get your next Pap test? 440(40.5) 396(36.5) 249(23.0)
Get a Pap test even if you are worried that it will be painful? 418(38.6) 438(40.4) 229(21.1)
Get a Pap test even if a friend discouraged you from having one? 475(43.8) 410(37.8) 200(18.4)
Get a Pap test even if you had to pay for it? 505(46.5) 381(35.2) 199(18.3)
HPV vaccination Self-Efficacy
Get the HPV if it is expensive 499(46.0) 386(35.6) 200 (18. 4)
Getting the shot, even if it hurts a little 477(44.0) 410(37.8) 198 (18.2)
Find time to go to the doctor many times. 420(38.7) 440(40.6) 225(20.7)

efficacy [AOR=2.874(1.241-6.653), P=0.014], and genital infection (82.1%), gynecological operation

[AOR=2.672(1.331-6.897), P=0.030], respectively. (52.4%), and family history of CC (96.7%) among
most of the studied women, which may give them a
Discussion sense of being at low risk. These reflect the cultural
The overall findings of the present study explored a background's influence, which was also explored
low intention for Pap smear screening compared to by a qualitative study by Jradi and Bawazir24, which
a high intention for HPV vaccination with a higher gave an in-depth elaboration of the cultural
self-efficacy level among the studied women. The concerns about screening and vaccination for
Pap testing intention was positively predicted by the classical sexually transmitted infection. In addition
increased women's age, having enough monthly to the inadequate perception of CC screening as
income, previous Pap testing, and high gravidity necessary, asymptomatic women deemed
and parity. The HPV vaccination intention was themselves not at risk. They believed that being a
positively predicted by women's rural residence and religious and conservative group is already at lower
having no family history of CC, whereas it was risk for such diseases.
positively predicted with high gravidity and parity. Three recent Studies proved a lower trend
Moreover, being divorced and a rural resident and for Pap testing intention. First, a Saudi study by
having no history of Pap testing/HPV vaccination Alissa25 examined Pap smear testing's knowledge
were negative predictors of self-efficacy. However, and intentions, signifying near average intention for
longer marriage duration and an increased number Pap testing. Besides, age and marital status were the
of gravidities and parities were the positive determinants of such intention. Second, an
predictors of self-efficacy level. Ethiopian mixed study by Getahun et al.26
The current study portrayed that more than investigated CC screening and revealed a low
half of the studied women have a low intention for intention among nearly half of the studied women,
Pap testing. A higher probability of pap testing was mainly due to cultural constraints. It explored a
seen among older women, those with enough fixed thought among women that this procedure can
family income, no previous Pap smear test, and hit the cervix and perforate the uterus, resulting in
high gravidity& parity. These reflect that older infertility; they also fear being misunderstood by
women who had many pregnancies and deliveries their community due to seeking CC screening
may perceive that they were at more risk for CC, services. Third, Alnafisah et al.27 assessed the
especially if they had not performed it before and women's knowledge and attitude toward CC screening
could afford it. It is worth mentioning that although in the Qassim region, proving that more than two-
most of the studied women were highly educated, fifths of the studied women completely refused to
there is low intention to perform pap smear testing. attend it in the future, which explored
These may be attributed to the free history of a a negative attitude toward it. However, they agreed

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Elgzar et al. Intention and self-efficacy for pap smear screening

Table 3: Binary logistic regression analysis of the associated factors with the intention and self-efficacy of the Pap
smear screening and HPV Vaccination

Pap smear screening intention HPV vaccine intention Self-efficacy

AOR (95% CI) p AOR (95% CI) p AOR (95% CI) p
Age
˂35year Ref
˃35 years 1.499(1.101-2.041) 0.010* 1.387(0.965-1.994) 0.078 0.969(0.674-1.394) 0.867
Education
Secondary school Ref
University or 0.823(0.618-1.096) 0.183 0.776(0.597-1.009) 0.059 0.829(0.629-1.091) 0.181
postgraduate
Marital status 0.441 0.590 0.119
Married Ref
Divorced 1.405(0.786-2.514) 0.252 1.302(0.774-2.188) 0.320 0.575(0.333-0.993) 0.047*
Widow 1.338(0.525-3.407) 0.542 0.910(0.372-2.227) 0.837 1.238(0.517-2.965) 0.631
Residence
Urban Ref
Rural 0.778(0.437-1.385) 0.394 0.536(0.307-0.936) 0.028* 0.489(0.274-0.872) 0.015*
Self-reported
Monthly income
Not enough Ref
Enough 1.669(1.090-2.557) 0.018* 1.121(0.775-1.623) 0.543 0.929(0.633-1.364) 0.708
History of
contraceptive use
Yes Ref
No 0.878(0.633-1.218) 0.436 0.945(0.695-1.285) 0.719 0.955(0.691-1.319) 0.779
Family history of
cervical cancer
Yes Ref
No 0.902(0.670-1.215) 0.499 0.689(0.374-0.972) 0.002* 0.868(0.653- 1.155) 0.332
History of pap smear
or HPV Vaccine
Yes Ref
No 0.287(0.049- 0.984) 0.038* 2.994(0.634-14.140) 0.166 0.187(0.039- 0.884) 0.034*
Age at marriage 0.738 0.039* 0.385
˂20year Ref
20-30 0.913(0.687-1.213) 0.529 1.322(0.979-1.791) 0.072 0.891(0.663-1.197) 0.444
˃30 years 1.063(0.594-1.903) 0.837 0.730(0.375-1.422) 0.355 1.260(0.675-2.349) 0.468
Marriage duration 0.031 0.047* 0.002*
˂10year Ref
10-20 0.673(400-1.133) 0.137 .715(0.490-1.043) 0.081 1.750(1.198-2.558) 0.004*
˃20 1.134(0.773-1.662) 0.520 1.012(0.631-1.625) 0.959 2.309(1.421-3.751) 0.001*
Gravidity 0.075 0.008* 0.044*
0 Ref
1-4 1.395(0.876-2.223) 0.161 3.952(1.936-11.390) 0.003* 2.874(1.241-6.653) 0.014*
˃4 1.745(1.054-2.890) 0.030* 5.812(1.965-12.233) 0.019* 2.468(0.997-6.107) 0.050*
Parity 0.079 0.012* 0.024*
0 Ref
1-4 2.620(1.061-6.469) 0.037* 4.552(1.646-12.590) 0.004* 2.672(1.331-6.897) 0.030*
˃4 1.616(0.956-2.731) 0.073 4.812(1.635-14.163) 0.004* 2.201(0.997-6.785) 0.007*
AOR: Adjusted Odd Ratio CI: confidence Interval *significant at p˂0.05

African Journal of Reproductive Health July 2022; 26 (7s):67

Elgzar et al. Intention and self-efficacy for pap smear screening

43.0
Self-Efficacy
57.0

37.5
HPV vaccination intention
62.5

59.5
Pap smear screening intention
40.5

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0

Low High

Figure 1: Participants’ total scores of intentions and self-efficacy for Pap Smear testing and HPV vaccination

that a Pap smear was necessary and agreed to The present study demonstrated that nearly two-
vaccinate their daughters. The author attributed this thirds of the studied Saudi women had high
to cultural traditions in the region. intentions for HPV vaccination. A lower probability
Two recent studies portrayed a higher of HPV vaccination intention was found among
figure. First, Sumarmi et al.17, who analyzed the rural women and those with no family history of
factors associated with Pap testing intention in CC. These might reflect that; rural women may be
Indonesia, depicted higher intention among the inadequately informed or lack access to health
highest percent (60%) of the studied women. services, while those with a free family history of
Second, Alemnew et al.19, who investigated the CC might perceive that they are at low risk and no
Ethiopian women's intention for CC screening, need to get the vaccine. In contrast, a higher
portrayed that more than half had an above-average probability of HPV vaccination intention was
intention for Pap smear. This discrepancy may be revealed among women of reproductive age and
attributed to the cultural and religious variations those with a high number of gravidity and parity,
where many ethnic groups were incorporated in the which may indicate their perception of the risk
latter study. Moreover, previous screening associated with being unvaccinated. Overall, this
experience was proved by both studies as a might mirror the awareness of Saudi women about
significant predictor of Pap testing intention. The the importance of the HPV vaccine and project
former study added other intention predictors, better coverage by the promised HPV
including income and educational levels and having immunization program in Saudi Arabia.Four recent
a friend or family with a history of CC. Moreover, studies go in line with these findings. Kim et al.30
age, residence, marital status, educational level, and revealed a high mean score for HPV vaccination
employment status were significant predictors of intention among Korean and Chinese women with
Pap testing among Saudi women (> 18 years) no significant difference. A Chinese study by Xu et
residing in Al Madinah Province by Zahid et al.28. al.27 and two Saudi studies by Akkour et al.32 and
Moreover, a Turkish study by Yanikkerem et al.29 Hussain et al.33 depicted that the highest percent of
added that pap testing was higher in married, older the participants reported their willingness to receive
women and those who had adequate income and the HPV vaccine, which investigated
had children than the nulliparous women. the awareness, attitudes, and perception toward the

African Journal of Reproductive Health July 2022; 26 (7s):68

Elgzar et al. Intention and self-efficacy for pap smear screening

HPV vaccine. Despite this willingness, worry, and those having higher parities and gravidities. These
uncertainty about HPV vaccine side effects, reflect that having children and family
effectiveness, availability, and cost were prevalent responsibilities may act as a pushing force that
in all studies. Evidently, Jradi and Bawazir24 and boosts women's belief in their abilities to protect
Akkour et al.32 revealed that Saudi women were their health for the sake of their families. In
less familiar with this novel vaccine. The latter addition, women's perception of the risk associated
indicated their willingness to be vaccinated, given with repeated pregnancies, deliveries, and regular
that being informed about it. Both highlighted that sexual intercourse for CC may be the other pushing
this might be a barrier to the success of the HPV force to do so. Evidently, Christy et al.38 confirmed
vaccination program, coupled with the cultural the mediating effect of self-efficacy for the
restrictions on CC screening practices. These relationships between the barriers' perception of
concerns shed light on the pressing need and HPV vaccination, the risk associated if not being
consolidated awareness-raising and advocacy vaccinated, and the final vaccination decision.
programs efforts. Moreover, Khodadadi et al.39, in examining the
A far lower intention level was reported by Latinx mothers' intention and perceived self-
Zhang et al.34, who analyzed the HPV vaccination efficacy for HPV vaccination, proved that those
uptake among Chinese university students, where who have lower self-efficacy have higher hesitancy
nearly one-third of them were willing to take it. This for HPV vaccination.
contrasting figure may be related to the lower mean Convenient findings were shown by
age of the participants in this contradictory study Chisale Mabotja et al.40, who revealed high self-
than the present one (18.99 vs. 37.79 years). efficacy for Pap testing among African women and
Conversely, a far higher intention level was proved that age was a significant positive predictor
detected by Wijayanti35, who reported that most of of self-efficacy. They studied women's beliefs and
the studied parents had a strong intention to perceptions regarding CC and Pap testing. An
vaccinate their daughters. These may be attributed Ethiopian study by Wollancho et al.16 investigated
to the parent's concern for their daughters' health, Pap testing intention and predictors. It showed good
plus that the Indonesian government has an self-efficacy among the participants. At the same
effectively established HPV vaccination program time, a small percentage of them expressed concern
since 2016 for girls (5–6 years). The determinants regarding lack of control due to the time consumed
of receiving HPV vaccination are varied among in doing the procedure while being the main
women by culture and country (with or without CC caregiver for the family. A Saudi study assessed
prevention program). The significant predictors women's knowledge and self-efficacy for CC
reported in recent literature for HPV vaccination screening by Ibrahim41 showed a moderate (55.8%)
intention include having a family member and to high (40.4%) self-efficacy among the highest
friend with cancer (Si et al.35), residence, and percent of the participants for Pap testing. A Korean
knowledge about CC and HPV vaccine (Le et al.36). study by Bossard and Song42 showed a high level of
In addition, Zhang et al.37 mentioned that being self-efficacy for HPV vaccination which was
married, urban residents and reception to HPV insignificantly varied by age, education, income,
vaccination counseling were also significant and the number of children. This insignificance
predictors. may be attributed to the higher mean age of the
The current study portrayed that more than women in this contradictory study (53.8) compared
half of the studied women had high self-efficacy for to 37.7 years in the present study, plus the culture
Pap testing and HPV vaccination. A lower and religious variation. Moreover, the history of
probability for self-efficacy was found among Pap testing was proved as a significant
divorced and rural women and those with no history predictor of high-self efficacy by Higgins et al.43,
of Pap smear tests or HPV vaccine. However, a who examined the intention and
higher o probability was detected among women self-efficacy for Pap testing among adolescents in
with longer marriage duration and high among the USA.

African Journal of Reproductive Health July 2022; 26 (7s):69

Elgzar et al. Intention and self-efficacy for pap smear screening

Strength and limitations of the study gravidities and parities were significant positive
predictors of self-efficacy.
The study explored well the intention and self-
efficacy for a sensitive topic in the Saudi culture, Recommendations
which is not adequately touched on in the literature. The current study recommends:
It also determined their predictors, which can - The Saudi government should put CC as the
further aid in developing a targeted intervention. top priority for action through fostering and
The limitation of the current study is devoted to the expanding the implementation of CC
designated sampling technique based on the social screening and HPV immunization programs.
media survey, which allows only the inclusion of - Developing advocacy programs for the
educated women who have access to an internet prevention of CC
network. - Campaigning for awareness-raising about CC
and cutting down the cultural concern about
Ethical considerations Pap testing
The investigators have obtained the Ethical Acknowledgment
approval for this study from the Nursing College,
Najran University (NU/RG/MRC/11/1). The The authors are thankful to the Deanship of
studied women get the questionnaire's link with Scientific Research at Najran University for
adequate clarification of the study's title and funding this work under the General Research
purpose with instructions for answering. Informed Funding program grant code (NU/RG/MRC/11/1).
online consent was gained from all the respondents Conflict of interest
before proceeding to the main questionnaire.
Women were also assured concerning their None
responses anonymity and confidentiality and that Authors' contributions
they were solely used to serve the study's purpose.
Women are also informed about the inherent Elgzar- The conception and design of the study and
voluntary participation, where they can decline analysis and interpretation of data, drafting the
their answers and withdraw at any time. article and revising it critically for important
intellectual content, final approval of the version to
Conclusion be submitted. Alshahrani- Drafting the article and
revising it critically for important intellectual
The present study concluded that the Saudi women content, final approval of the version to be
in Najran city had an overall low intention for Pap submitted. Nahari- Drafting the article or revising
smear screening. In contrast, they had a high it critically for important intellectual content, final
intention for HPV vaccination and a higher self- approval of the version to be submitted. Al
efficacy level. The significant positive predictors of Thubaity- The conception and design of the study
Pap testing intention were increasing women's age, and analysis and interpretation of data, drafting the
enough monthly income, previous Pap testing, and article and revising it critically for important
high gravidity and parity. The women's rural intellectual content, final approval of the version to
residence and having no family history of CC were be submitted. Ibrahim- The conception and design
negative predictors of the HPV vaccination of the study, drafting the article. Sayed- Revising
intention, whereas high gravidity and parity were the article critically for important intellectual
the positive predictors. Moreover, being divorced content, and final approval of the version to be
and a rural resident and having no history of Pap submitted. El Sayed- drafting the article and
testing or HPV vaccination were negative revising it critically for important intellectual
predictors of self-efficacy. However, longer content, and final approval of the version to be
marriage duration and the increased number of submitted.

African Journal of Reproductive Health July 2022; 26 (7s):70

Elgzar et al. Intention and self-efficacy for pap smear screening

17;9(1):e984. doi: 10.7759/cureus.984. PMID:

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