Introduction

Cervical cancer continues to be the leading female genital cancers and considered a major public health challenge globally [1]. Worldwide it is the fourth leading cancer among women. Generally the risk of getting cancer is higher in the developed world, but cancers in the developing world are more fatal due to lack of awareness and delay in availing healthcare. Only 19% of the world population lives in the developed countries where 46% of new cancer cases occur [2,3]. Cervical cancer is largely a disease of the developing countries [3,4]with higher care fatality rate [5]. Inspite of being a preventable and curable cancer the mortality rates associated with cervical cancer are expected to increase in the next decade by 25% [6].

Sankaranarayanan R et al. reported that in low-resource setting, a single round of HPV testing was associated with a significant reduction in the number of advanced cervical cancers and related deaths [7]. This highlights the focus on preventive strategy for cervical cancer.

In United Arab Emirates cancer is the third leading cause of death following cardiovascular diseases and road traffic accidents. It accounted for 10% of total deaths in 2019 [8]. Cervical cancer is the 5th most frequent cancer among women in UAE and the third common genital malignancy with an incidence of 6.2 and cumulative risk of 0.7% [9].

Effective screening can facilitate early detection, treatment thereby dramatically reducing mortality rates. The interface between those screening patients and those most needing screening is complex and women in remote rural areas face additional barriers that limit the effectiveness of cancer prevention programs. Community outreach strategies, can improve the utilization of screening program [10,11].Utilization of services depends on the stage of change in behavior. It is seen that action and maintenance in health seeking behavior can be improved by interventions addressing these stages of behavior change [12]. Regarding Pap testing, as a screening method for cervix cancer, it is observed that awareness about the disease, encouragement from health care provider and insurance coverage are the key determinants for utilization [13,14]. A new promise for primary prevention strategy for HPV infection and cervical cancer has gained momentum following the availability of effective prophylactic HPV vaccines. However, these vaccines are mainly found to be effective only in those who are not yet exposed to the virus [15].

Cancer screening programs over the years in UAE has made significant progress but still currently there is no UAE wide national screening programs [16]. The awareness regarding causative role of HPV in cervical cancer and use of available screening methods/ HPV vaccine for prevention is still low among general public. Additionally the barriers for utilization pose a significant challenge. The objective of this study is to assess the knowledge, attitude, practice of women in UAE regarding cervical cancer screening, prevention and barriers for utilization of screening program.

Materials and methods

The Multi-centre based study was conducted in selected northern emirates in the UAE. This study was conducted by Department of Obstetrics and Gynaecology of Thumbay Hospital Ajman, United Arab Emirates. This study employed cross-sectional design involving women above the age of 19 years. The study was conducted among three Thumbay hospitals in Ajman, Sharjah and Fujairah. For the calculation of the sample size, the proportion of females with knowledge on breast and cervical cancer was considered as 50%, significance level as 5% and marginal error as 5% (10% of the prevalence). Hence the minimum sample size required for this study was 400.

A baseline assessment of awareness on various parameters related to risk factors of cervical cancer among women was assessed. Current level of knowledge and practice involved in the prevention, early diagnosis and treatment of cervical cancer was assessed. Utilization of healthcare facility by the participants for early diagnosis and treatment of cervical cancer was determined. Participant’s perspective on availability, accessibility, affordability and acceptability of screening programs of cervical cancer was studied in detail.

The research tool comprises of structured close-ended and open-ended questions. List of responses for the close-ended questions was printed below each question to facilitate on the spot marking by the interviewer. For the open-ended questions space was provided to write down the replies in verbatim.

The research tool was provided with the information in the following areas:

a. Demographic parameters.

b. Questions concerning history cervical cancer, family history of cancer.

c. The subjects’ awareness of cancers, attitude of study subjects towards risk factors of cervical cancers, screening programs, preventable nature of cancers, importance of early diagnosis and awareness regarding cancer screening, the risk factors for cancers, the subject’s exposure to the risk factor.

d. Awareness regarding HPV vaccine.

Ethics Committee approval was taken from Ethics and Research committee of Gulf Medical University. An informed consent form was prepared and written signed consent was obtained before administering the questionnaire and the identity of all the participants was kept confidential.

Approval was sought from the authorities prior to the conduct of the research. A face to face interview was conducted by the investigators after obtaining consent from the study subjects.

Data were entered into excel spread sheet. Analysis was performed using SPSS version 22. A descriptive analysis of the baseline data was carried out first. All variables were analyzed in aggregate and by socio-demographic information. Tests were considered significant when the p value <0.05. Univariate analysis was carried out for each factor and the odds ratio and corresponding 95% confidence intervals were presented. A multivariate analysis was done by incorporating significant variables.

Result

In total, 401 women in the northern emirates constituted the study population. Majority of respondents were of age group between 26-39 years (64.8%). Of total, 59.10% respondents were literate and majority was Asian (73.1%). Married women were more (77.6%) as compared to unmarried (16.7%) (Table 1).

Table 1: Distribution of participants with respect to their Socio demographic characteristics (N=401).

Table 2: Distribution of participants according to their reproduc- tive history (N=401).

On considering the reproductive history, 83.6% had their menarche at age group 11-14 years. 73.1% opined that the best age for marriage is >25 years and 84.2% subjects had children, 53% preferred to have 3-5 children. Maximum respondents (51.2%) had their first child in the age group of 19-25 yr. 87.2% had breast fed their child (Table 2).

25% of participants had family history of malignancy out of which 68% had 2nd degree relatives. 44% had breast cancer and 7% gynaecological cancer (Table 3).

Table 3: Distribution of participants according to their family history (N=401).

Table 4: Distribution of participants with respect to their Socio demographic characteristics (N=401).

Regarding cervical cancer and screening programs, the questionnaire includes 18 questions from knowledge part and 3 from practice part. The participants who had correct knowledge and practice, a score of 1 was given and a score of 0 was assigned to the participants who had incorrect knowledge and practice. A variable “knowledge score on cervical cancer” will be available when scores of each knowledge questions for each sample are added and it range from a minimum score of 0 to maximum score of 13. In the obtained knowledge score, score of 0 is considered as “no knowledge”, a score from 1-9 as “below average score” and score >9 as “above average score”. In the knowledge part, some sub-topics are not applicable for participants to answer if they don’t have knowledge about its main topic. Such “not applicable cases” are also taken with a zero score. In the scoring system, the missing information was also considered with a 0 score since they would have chosen any of the option if they had knowledge about it.

With respect to cervical cancer, majority of the participants had below average knowledge (Table 4).

Table 5: Participant’s knowledge on cervical cancer and screening programs (N=401).

Table 6: Comparison between knowledge and practice on HPV and Pap smear test.

Respondents were probed for their level of knowledge and awareness on screening programs about cervical cancer. 99% of the respondents had heard about cervical cancer, 36% had correct knowledge, 42% knew the cause and 54% were aware of disease cure if detected early. Respondent were queried about the risk factors for cervical cancer and 57% & 40% had correct knowledge about family history & viral infection-HPV, Multiple sexual partners respectively. However the knowledge about other risk factors like smoking, multiparity, sex at early age and use of birth control pill were poor. 48% had knowledge on availability of vaccine and only 15% knew the right age for vaccination. 53% knew the reason for Pap smear screening (Table 5).

Regarding those with correct knowledge of getting HPV vaccination only 23.2% of the participants got vaccinated. But 76.8% did not get vaccinated in spite of knowledge and awareness of HPV vaccine. Regarding those with correct knowledge regarding recommendation of Pap smear test only 31.3% of the participants practiced it correctly (Table 6).

Study results showed that 62.8% women who experienced Pap smear were satisfied with the test. 43.5% opined that Pap smear test gave them a sense of control. 57.5% felt regular Pap smear is valuable to them (Table 7).

Table 7: Attitude on benefits of Pap-smear test among Participants’ who had Pap-smear test.

Table 8: Participant’s attitude towards future plans on “Pap smear test” based on their practice/experience.

Table 9: Distribution of attitude on cervical cancer susceptibility/severity and their practice.

Among the participants who had PAP -smear test in the past, majority of them (73.7%) are planning to have the same in future. Among the inexperienced, 68.7% also want to get Pap smear in future. Those who had PAP-smear test, 48.1% wanted to receive the result face to face. 72.1% preferred women to perform the test for them (Table 8).

Among participants there is no significant variation in their belief on chance of having Pre-cancerous lesions & in their attitude on getting vaccinated against HPV in both groups (Tables 9 & 10).

Table 10: Attitude on getting vaccinated against cervical cancer and its practice.

Table 11: Association between barriers in performing “Pap smear test” and its practice.

Study results about the barriers for cervical cancer screening (Pap smear) showed that 42.6% felt having Pap smear is a painful experience. 29.6% opined difficulty to extract time from work for having Pap smear test. 32.5% were afraid of detecting cervical cancer and 31.7% felt uneasy talking about cancer (Table 11).

Discussion

Cancer cervix

In our study low level of knowledge about cancer cervix was observed with only one third of study participants having the correct knowledge. Participants with asian ethnicity and higher educational background had better knowledge. Similarly higher level of knowledge was observed by Alem Getaneh et al (2021) [17] in their study among university female students. Contrary to the above Syed et al (2022) [18] observed considerable low level of knowledge among health professions students.

Awareness on prevention

Cancer cervix prevention awareness was higher with half of participants knowing about cervical cancer screening. Though they did not know what cervical cancer screening entailed or screening methods, they still believed that it is important since like for other cancers will help in early detection and treatment. Kim HW et al (2015)[19] observed inadequate level of awareness and preparedness among mother of adolescent daughters with respect to prevention of cervical cancer in their daughters.

Practice & attitude

Utilization of cervical cancer screening services among women however was low. Around one third (31.3%) practiced Pap smear and one fourth (23.2%) got vaccinated against HPV. Similar were the observations in a Nigerian study [20]. However participants were enthusiastic to have Pap smear in future with more than two thirds of them opting for the same. This shows a positive attitude among women about Pap smear screening.

Among the participants who showed positive attitude towards HPV vaccination only 17.3% got vaccinated. This again shows wide gap in utilization of prevention program.

Barriers for utilization of cancer prevention

Lack of awareness or improper knowledge about cervical cancer screening (as witnessed in around two third of study population) is the greatest individual level barrier for utilization of cervical screening program. Among Pap smear screened participants 42.6% felt uncomfortable having Pap smear. This could probably be attributable to ineffective counseling prior to procedure or woman’s anxiety. About a third among working women felt the time constraint as a barrier for future screening. Fear of getting a positive report, uneasy to talk about cancers are the other individual factors acting as barriers for utilization of screening.

Petersen Z et al (2022) [21] in a systematic review observed similar individual barriers impacting utilization. Additionally his study also elicited other barrier like cultural, religious, structural, societal and health system barriers to screening. These possibly identified barriers were unsupportive partners/family members, screening cost, misconceptions in the community, defective policies/programs impacting cancer prevention program.

Conclusion

Majority of study population had poor knowledge about cervical cancer screening and preventive modalities for the same. These observations highlight lack of awareness and information on cervical cancer and screening in the community. Creating awareness and translating the knowledge into practice among women in UAE is the key to success as screening programs which were implemented in developed countries had proved to be effective in reducing the incidence of the cancer and associated mortality.

Uniform nation wide cervical cancer prevention programs coupled with community advocacy, information dissemination, addressing the individual, cultural, social barriers for utilization and supportive healthcare delivery system, are the need of the hour for speedy implementation of program to achieve the desired goal.

Recommendations

Increasing the women’s awareness is an important first step towards cancer screening and prevention in UAE. This can be promoted by informing the women on their susceptibility to cervical cancer and encouraging a belief that active and regular screening can detect these cancers at early (pre-cancerous) stage, thereby enabling the early treatment and attaining a lower incidence and mortality. The national health care system should facilitate the development of effective strategies (well defined national cancer screening program) which are needed to ensure that women get screened/vaccinated at the appropriate age and regular intervals and creating an effective environment for utilization of screening services by overcoming the barriers identified.

Limitations

This study had some limitations which may have influenced the result of the study.

Being a multicentric study there could have been a variation in the method of interviewing the participants which may have influenced the results. Secondly, women may have responded in a positive manner to the questions to present themselves in a socially desirable way. Similarly responses are all self-reported and may not reflect true events.

References

1. Ali F, Kuelker R, Wassie B. Understanding cervical cancerin the context of developing countries. Ann Trop Med Public Health. 2012; 5: 3-15.
2. http://www.cancer.org/downloads/AA/CancerAtlas11.pdf accessed on 25th March 2023.
3. http://www. cancer.org/downloads/AA/Cancer Atlas12.pdf accessed on 5th May 2023.
4. http://www.fightcervicalcancer.org.uk/cervical-cancer/benefits.aspx accessed on 5th May 2023.
5. Abudukadeer A, Azam S, Mutailipu AZ. Knowledge and attitude of Uyghur women in Xinjiang province of China related to the prevention and early detection of cervical cancer. World J Surg Oncol. 2015; 13: 110.
6. El Banna N, Al Eyd G, Saeed RS. High risk human papilloma virus infection among women with Pap smear tests negative for intraepithelial lesions or malignancy. Int J of Med Pub Health. 2014; 4: 102-6.
7. Sankaranarayanan R, Nene MB, Shastri SS. HPV screening for cervical cancer in rural India. NEJM. 2009; 360: 1385-1394.
8. UAE Ministry of Health and prevention. https: //mohap.gov.ae/assets/download/f3eb10c9/CANCER%20INCIDENCE%20IN%20UNITED%20ARAB%20EMIRATES%20ANNUAL%20REPORT%20OF%20THE%20UAE%20-%202019.pdf.aspx
9. WHO cervical cancer country profile 2021. 2021.
10. Markman. Development of an effective breast and cervix cancer screening strategy in Mumbai: an impressive effort. Oncology 2007; 73: 143-4.
11. Christe DM, Mohanambal M, Ramamurthy V. A study of cervical cancer screening for prevention of carcinoma cervix. J Indian Med Assoc. 2008; 106912: 779-80.
12. Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am J Health Promo-tion. 1997; 12: 38-48.
13. Campbell MK, Tessaro I, DeVellis B. Tailoring and targeting a worksite health promotion program to address multiple health behaviors among blue-collar women. Am J Health Promotion. 2000; 14: 306-313.
14. Kelaher M, Gillespie AG, Allotey P. The trans theoretical model and cervical screening: its application among culturally diverse communities in Queensland, Australia. Ethnicity and Health. 1999; 4: 259-276.
15. Schiller JT, Castellsagu X, Villa LL, Hildesheim A. An update of prophylactic human papillomavirus L1 virus-like particle vaccine clinical trial results. Vaccine. 2008; 26: K53-K61
16. Humaid O, Al Shamsi. The state of cancer in United Arab Emirates. Clin. Pract. 2022; 12: 955-985.
17. Alem Getaneh, Birhanemeskel Tegene, Teshome Belachew. Knowledge, attitude and practices on cervical cancer screening among undergraduate female students in University of Gondar, Northwest Ethi-opia: an institution based cross sectional study. BMC Public Heath. 2021; 21: 775
18. Syed Sammer Aga, Nusrath Yasmeen, Muhammed Anwar Khan. Cervical Cancer and Its Screening: Assessing the Knowledge, Awareness, and Perception among Health and Allied Students. Education Re-search International.Volume 2022; 4608643.
19. Kim HW, Kim DH. Awareness of cervical cancer prevention among mothers of adolescent daughters in Korea: Qualitative research BMJ Open. 2015; 5: e006915.
20. Ndikom, Chizoma M, Ofi, Bola Abosede. Awareness, perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: A qualitative study. Reproductive Health. 2012; 9: 11.
21. Petersen Z, Jaca A, Ginindza TG. Barriers to uptake of cervical cancer screening services in low-and-middle-income countries: a systematic review. BMC Women’s Health. 2022; 22: 48.