Practice and Barriers towards Pap Smear Test from a Public Hospital in Malaysia

Community Medicine Department, International Medical School, Management and Science University, Malaysia

Corresponding Author:

Redhwan Ahmed Al-Naggar
Community Medicine Department
International Medical School
Management and Science University, Malaysia
E-mail: radhwan888@yahoo.com

Received Date: February 22, 2012; Accepted Date: March 17, 2012; Published Date: March 19, 2012

Citation: Al-Naggar RA (2012) Practice and Barriers towards Pap Smear Test from a Public Hospital in Malaysia. J Community Med Health Edu 2:132. doi: 10.4172/jcmhe.1000132

Copyright: © 2012 Al-Naggar RA. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Keywords

Practice; Barriers; Pap smear test; Malaysia; Cervical cancer screening

Introduction

Human Papillomavirus (HPV) infection is widely recognized as the most common sexually transmitted infection [1-3]. Studies have established a strong association between HPV genotype 16 and 18 and cervical cancer. HPV infects almost all women at some point in their lives. Approximately 50% of women have evidence of an HPV infection within the first 3 years of sexual intercourse [4].

Studies have shown that 91% of new HPV infections are cleared by the immune system within two years. However, the virus exerts greater effects during periods of rapid metaplasia in the cervical epithelium, mostly in the period of adolescence [5]. A small proportion of infected persons become persistently infected; persistent infection is the most important risk factor for the development of cervical cancer precursor lesions.” Most studies suggest that young age is a risk factor for HPV infection due to the greater extension of the transformation zone of the cervix. Therefore, certain sexual behaviors such as early sexual intercourse before 20 years and sexual promiscuity, either in the female or her partner are known to prompt cervical cancer number of lifetime sexual partners”, either in the female or her partner are also known as relevant risk factors for cervical cancer [6,7].

Cervical cancer is the second most common cancer among women worldwide since 1990 [8] and it is still the second most common cancer among women with about half million new cases and 250,000 deaths yearly worldwide [9]. Cervical cancer has higher incidence rates in developing countries [10,11].

The Pap smear test is a simple method that can detect abnormal cells from the cervical epithelium. It is still the most suitable approach for Cervical Cancer screening as it is a fast, easy-to-perform, painless test performed on an outpatient basis at low cost that has proven effective and efficient for mass screening [12-14]. The progression of lesions to invasive cancer is slow and most lesions are asymptomatic but can be detected by cervical screening [15]. Despite the possible detection of cervical cancer in its premalignant stage, cervical cancer remains the second most common cancer among Malaysian women [16]. The Pap test effectiveness in reducing Cervical Cancer mortality rates has been assessed in comparative studies of time trends that showed significant rate reduction in some countries after the introduction of Pap smear test programs. Millions of women’s lives have been saved because of early detection with Pap smear test which has been proven to be an effective tool to control cervical cancer [17]. There is ample evidence to suggest that screening is effective in reducing cervical cancer since the rate of new cervical cancers has fallen between 30% and 78% in countries with organized screening programs [18].

Cervical cancer is a preventable disease. The natural history of Cervical Cancer reveals that it has great potential for prevention and cure as it slowly progresses through several stages of precancerous intra epithelial lesions before developing into an invasive form [13,19]. This characteristic associated to the relatively easy diagnosis allows detecting this disease at early stages when treatment results in high cure rates. In addition, the infectious nature of Cervical Cancer etiology makes preventive actions feasible, including vaccination against two HPV types with greater oncogenic risk [20,21,22].

The cervical cancer prevention can be done with primary, secondary and tertiary prevention. The primary prevention is reduced risk factors such as no sexual intercourse at young age, limit sexual partners (monogamous relationship). Primary prevention encompasses the elimination or reduction of exposure to recognized risk factors in susceptible populations to prevent a disease, the health education to promote the use of condoms for sexual intercourse (especially amongst young women), sexual partner reduction and negotiated safer sex strategies have been recommended as a necessary approach to limit the spread of HPV. Primary prevention of cervical cancer also includes HPV vaccine which can prevent HPV type 16 and 18 infection [23,24]. Secondary prevention is the detection and treatment of premalignant lesion before it turns into an invasive cancer [25-27].

The tertiary prevention involves the treatment of confirmed cases of cervical cancer and how to minimize the injury and improve quality of life.

In Malaysia, after more than 50 years of the implementation of Pap smear screening services, the uptake of Pap smear screening in Malaysia remains low. The Second National Health and Morbidity Study reported that only 26 % of eligible women aged over 20 years in Malaysia had undergone Pap smear screening in 2000. This figure rose slightly to 43% as shown by the data which were collected in the Third National Health and Morbidity Survey 2006. The aim of this study was to determine the practice and barriers towards Pap smear test among Malaysian women from a public hospital in Selangor, Malaysia.

Methodology

This study used a cross-sectional, descriptive design. A convenience sample of 142 women aged 18 to 70 years was recruited from the waiting rooms of Obstetrics & Gynaecology ambulatory at Tengku Ampuan Rahimah Hospital, Klang, in Selangor, Malaysia. Data collection started in September 2011 and ended in January 2012. Selfadministered questionnaires were distributed around the waiting area in the clinics during clinic’s hours from 9.00 A.M until 1.00 P.M. They were answered and completed on the spot. The inclusion criteria were female patients who are 18 years old or over and have the ability to speak and understand Malay since the language used in questionnaire were in Malay. On the other hand, the exclusion criteria include women who are younger than 18 and older than 70 years and unable to speak Malay. The proposal of this study was approved by the ethics committee of Management and Science University (MSU). The consent letter was then given to the participant in order to get their permission to be part of this study. The patients were asked if they were willing to complete the survey. If agreed; full explanation on the purpose of the study was given and then consent form was obtained from each participant. The questionnaires consist of 33 questions included socio-demographic such as (age, race, education, occupation, husband’s occupation, family monthly income, marital status, age at marriage, number of partners, and menopause status). The questions also asked about the practiced, barriers and source of information. Data analyzed using the Statistical Package for Social Sciences (SPSS) version 13.0. Descriptive analysis had been done in order to give the view of frequency and percentage. T-test was used in univariate analysis. Multiple linear regression using backward analysis was performed to obtain the final model. The final model was chosen depending on R² and the p value of the model. A p value less than 0.05 are considered significant.

Results

A total number of 142 patients participated in this study, mean age was 31.55 (SD ± 8.17); with age ranging from 18 to 53. The majority of them were younger than 35 years old, Malay, with family monthly income less than 3000 Ringgit Malaysia (RM), with primary and secondary education and single (62%, 68.3%, 64.1%, 73.2%, 88.7%; respectively). The majority of them had heard about Pap smear test (72.5%). Regarding the factors associated with practice of Pap smear test, age, marital status and to have heard about Pap smear influenced significantly the practice of Pap smear test (p=0.001, p=0.001, p=0.001; respectively) (Table 1).

Table 1: Socio-demographic of the participants and factors associated with practice of Pap smear (n=142).

Regarding the practice of Pap smear test; almost half of the study participants (46.5%) reported that having at least one Pap smear in their lifetime. Only 14.8% of them do Pap smear test screening on a yearly basis (Table 2).

Table 2: Practice towards Pap smear test among the study participants (n=142).

Regarding the source of the information, the majority of the participants (57.7%) mentioned that doctors/hospitals/clinics were their sources of information about Pap smear test. Followed by printed media such as newspapers, magazine, books and flyers (43.7%). Then electronic media such as radio and television (31.7%). The lowest source mentioned by the participants was information at workplace (12.7%) (Table 3).

Table 3: Source of information about Pap smear test among the study participants (n=142).

Regarding the reasons for uptake Pap smear test, the highest percentage of the participants (36.9%) mentioned that the reason for uptake Pap test was cervical cancer detection; followed by (30.3%) health purposes. Then the lowest percentage (2.8%) did the Pap smear test because there were medical or self suspicious of cervical cancer (Table 4). Regarding the barriers towards Pap smear test, place of screening (15.5%) was mentioned as the main barrier, followed by don’t have time (11.3%). Then the lower percentages were no female doctor availability, the hospital and the clinic far and the virginity will be taken away (2.1%) (Table 5).

Table 4: Reason for Pap smear screening among the study participants (n=142).

Table 5: Barriers towards Pap smear among the participants (n=142).

In multivariate analysis, only marital status has significantly influenced the practice of Pap smear test among the study participants (Table 6).

Table 6: Multivariate analysis.

Discussion

This survey provides baseline information for planning a cervical cancer prevention programme in Malaysia. In this study the majority of the participants mentioned that their source of information about Pap smear test were healthcare providers. Similar study reported that face to face interaction with clinicians were preferable to audio/visual information [28]. The other source of information was printed media (Newspaper, Magazine, books, flyers), followed by Electronic Media (radio/Television). This may be due to printed materials like magazines and books are not popular sources because of their format, such as length, lack of appeal, and lack of specific information [28]. The same study reported that women stated that magazines and books often contain complex material with medical terminology that is too long and difficult to comprehend and do not reach women of low literacy. Additionally, women placed little trust in the information from television and radio, finding these media commercial and entertaining, but not educational [28]. A study from Qatar showed that the majority women got their knowledge about cervical cancer screening from their social network (relatives and friends) rather than physicians or the media [29]. Few women used Internet (21.8%) as information source about Pap smear test. This may be due to only few women in this study had access to and knowledge of how to use a computer and/or the Internet. Similar data were reported by McCree et al. [28].

It is well known individuals’ knowledge and beliefs about the cause and significance of a particular illness are interconnected with their healthcare-seeking behaviors [30]. Knowledge about Pap smear has significantly influenced the practice of Pap smear screening. Our results are consistent with previous studies [31,32]. A populationbased study of 3197 women in Morelos, Mexico, showed that women who were aware of the purpose of the Pap smear were three times more likely to use screening than women who did not know the purpose [31]. A cross-sectional study carried out in Mexico City reported that women who knew the benefits of Pap smears were six times as likely to participate in screening programs [32]. The findings of this study indicate that in Argentina the lack of knowledge was associated with not being screened; therefore, increasing women’s knowledge about cervical screening may be a key first step of any strategy to increase coverage among women who are under-screened. Similar finding was reported by other studies that women’s knowledge has influenced their screening behavior [33-38]. Therefore there is a need to educate women on the role of HPV in the cause and risk factors of cervical cancer and its prevention. The mass media plays a vital role in this context and its function should be optimized [39]. Other studies support our findings that health education appears to have an important role to play in increasing knowledge and addressing some of the negative biases the young women have against the test [40]. Awareness campaign should be intensified through hospital visits, mass media and public lecture [40]. These results were also supported by a qualitative study among African Americans women which found that demystification of personal beliefs and providing correct information might increase screening rates [41].

In this study, marital status has significantly influenced the practice of Pap test among the study participants. Similar finding was reported by other studies [42,43]. A possible explanation may be due to Pap smear is considered a routine procedure during antenatal care and part of family planning. Another possible explanation is that married women may be more likely to visit a doctor for reproductive health care. Similar study found that Pap smear screening was significantly related to marital status [44]. In another study from Malaysia, Pap smear screening was also significantly associated with marital status [45]. Similar findings were reported by Norwegian female physicians, there was a significant correlation of Pap smear screening and married women [46]. Another study evaluating Korean-American women showed stronger correlation of Pap smear with marital status [47].

In this study, age has significantly influenced the practice of Pap smear among the study participants. Similar findings were reported by several studies [48-59]. Our findings in a previous study among university students that there is a relationship between age and knowledge about cervical cancer screening were confirmed again in this study [39]. Another study also showed that age was associated with knowledge about Pap smear test [60].

The practice of uptake Pap smear test depends on a range of factors that include the healthcare system and its professionals and the women [61]. This study has focused on the practice of Pap smear test from the point of view of women only. It has been estimated that only about 5%– 10% of women in developing countries [62-64] have been screened for cervical cancer with a Pap smear compared to 40%–50% in developed countries [65]. Almost half of the study participants (46.5%) had ever done Pap smear test. Only 14.8% of them do Pap smear test screening on a yearly basis. Higher percentage was reported among Vietnamese- American women (76%) [66]. This study showed a lower percentage of practice of Pap smears when compared to another study from Argentina which reported that 86.8% of the women had ever had the test [42]. One study from Hong Kong reported that the self-reported cervical screening uptake of the 319 interviewed clinic attendees was 47.2% during the previous 12 months [67]. In a Qatar study, almost 40% of the women had had at least one Pap smear [29]. The practice of Pap smear in a study from Kuwait was 23.8% [61].

Several barriers towards Pap smear test were identified in this study; lack of knowledge was the commonest barrier among the participants. In this study the greatest barriers mentioned by the participants was never heard about Pap smear test. That means there is insufficient knowledge about the Pap smear test. The use of the Pap test for cervical cancer screening will not increase unless knowledge is improved and barriers are partially eliminated. Providing information through leaflets and giving clear explanation about the test procedure can help in reducing anticipated distress and embarrassment [61].

The study participants mentioned that male health workers are a barrier to do Pap smear test. This is consistent with other Asian studies which reported women preference for female doctors to perform physical examination on intimate body parts and high embarrassment level with male health providers [35,66]. A study from Mexico also showed that women agreed being examined by a male sample taker would discourage them from getting a Pap smear test [68]. Other similar studies [69-71] reported that the anxiety of potentially being faced with a male sample taker was a significant problem. Another study from Kuwait reported that about 79% of the respondents would prefer a female to conduct the Pap smear test [61]. Similarly; a study from Hong Kong reported that many Hong Kong women did not prefer to have their genital parts examined by a male physician [72]. Lazcano-Ponce et al. [31] reported that being examined by male is one of the barriers of Pap smear test screening among women. Research has shown that easy access to female physician contributed to the increased likelihood of receiving a Pap smear test [35]. The possible explanation may be due to religious affiliation and cultural beliefs, Muslim women in particular felt most comfortable with female health care providers. Several studies reported that the most common reasons in patient who avoid Pap smear are fear of vaginal examination, embarrassment and not concern the risk [73-79].

About 15.5% of the study participants mentioned that lack of information about screening sites is one of the barriers of Pap smear uptake. A similar finding was reported by other studies [39,80]. Higher percentages than this study were reported by Ayinde et al. [40] and Aniebue and Aniebue [81] 16% and 34%; respectively of the study participants had lack of knowledge of centres where the test could be done. The Centres and places of screening should be easily addressed with simple information in order to allow women to know where the test should be done.

Some of this study participants mentioned that pain is one of the barriers towards Pap smear test. Similar studies reported that fear of pain and lacks of hygiene prevent women from attending Pap smear test screening [87,88]. Pain and embarrassment were reported by Lazcano-Ponce et al. [31] as a barrier. Wong et al. [89] reported that an expectation of pain and discomfort during the procedure was another barrier to screening among these women. Misconception about the test being painful have also been reported in other studies [34,76,90]. Fear of infection was reported by others [34,76,90].

In this study, no encouragement from the husband/family/friends was one of the barriers to do Pap smear test. Al-Naggar et al. [39] reported that the least common barrier reported among participants was no encouragement from the partner. A similar finding was reported by Abotchie and Shokar [80] one of the barriers among the study participants was whether their partner would want them to have a Pap smear test. This finding has implications of public health interventions and suggests that broad based public health initiatives will be needed to overcome these barriers [80].

Some of the study participants mentioned that the worry is a barrier for them to uptake Pap smear test. Similar studies reported that fear and anxiety in association with participation in Pap smear screening [39,91]. Fear of discovery of cancer is one of the barriers reported by other studies [34,76,90]. Several studies from other countries [92- 94] also indicate that embarrassment is a major factor that prevents women from performing the Pap test. The concept of embarrassment can be associated with strong cultural factors since majority of women mentioned being shy if they have to expose their private parts and Pap smear test is a very intimate procedure.

This study has limitations on the design and sampling. It was a cross-sectional study. Screening was self-reported data without comparison to any objective medical records and thus the identified factors may be different from those related to the actual cervical screening.

Conclusion

A well-designed health education programme on cervical cancer and benefits of screening would increase the awareness among women. On that issue, a multimedia approach utilizing pictorials, audio-visual and personal communication on cervical cancer could yield beneficial results. One more important point is the fact that better communication with health professionals and improvement of access to health care services should increase the rate of cervical cancer screening. Efforts to increase awareness should target women who are older, unmarried, less educated, and of low income.

Recommendation

The findings of our study suggest that it is important to provide information about the value of cervical smear test and to contradict barriers. Providing information through leaflets and giving clear explanation about the test procedure can help in reducing anticipated psychological distress and embarrassment. Since it is well established that satisfaction is a predictor of compliance, it is important to examine ways of increasing women’s satisfaction with the provided cervical cancer screening service.

Acknowledgements

The author would like to thank the director of Tengku Ampuan Rahimah Hospital, Klang, Selangor, and Head of Department of Obstetrics & Gynecology. I would also to extend my thanks to Diana for collecting the data and to all the patients who voluntarily agreed to participate in this study.

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Keywords

Practice; Barriers; Pap smear test; Malaysia; Cervical cancer screening

Introduction

Human Papillomavirus (HPV) infection is widely recognized as the most common sexually transmitted infection [1-3]. Studies have established a strong association between HPV genotype 16 and 18 and cervical cancer. HPV infects almost all women at some point in their lives. Approximately 50% of women have evidence of an HPV infection within the first 3 years of sexual intercourse [4].

Studies have shown that 91% of new HPV infections are cleared by the immune system within two years. However, the virus exerts greater effects during periods of rapid metaplasia in the cervical epithelium, mostly in the period of adolescence [5]. A small proportion of infected persons become persistently infected; persistent infection is the most important risk factor for the development of cervical cancer precursor lesions.” Most studies suggest that young age is a risk factor for HPV infection due to the greater extension of the transformation zone of the cervix. Therefore, certain sexual behaviors such as early sexual intercourse before 20 years and sexual promiscuity, either in the female or her partner are known to prompt cervical cancer number of lifetime sexual partners”, either in the female or her partner are also known as relevant risk factors for cervical cancer [6,7].

Cervical cancer is the second most common cancer among women worldwide since 1990 [8] and it is still the second most common cancer among women with about half million new cases and 250,000 deaths yearly worldwide [9]. Cervical cancer has higher incidence rates in developing countries [10,11].

The Pap smear test is a simple method that can detect abnormal cells from the cervical epithelium. It is still the most suitable approach for Cervical Cancer screening as it is a fast, easy-to-perform, painless test performed on an outpatient basis at low cost that has proven effective and efficient for mass screening [12-14]. The progression of lesions to invasive cancer is slow and most lesions are asymptomatic but can be detected by cervical screening [15]. Despite the possible detection of cervical cancer in its premalignant stage, cervical cancer remains the second most common cancer among Malaysian women [16]. The Pap test effectiveness in reducing Cervical Cancer mortality rates has been assessed in comparative studies of time trends that showed significant rate reduction in some countries after the introduction of Pap smear test programs. Millions of women’s lives have been saved because of early detection with Pap smear test which has been proven to be an effective tool to control cervical cancer [17]. There is ample evidence to suggest that screening is effective in reducing cervical cancer since the rate of new cervical cancers has fallen between 30% and 78% in countries with organized screening programs [18].

Cervical cancer is a preventable disease. The natural history of Cervical Cancer reveals that it has great potential for prevention and cure as it slowly progresses through several stages of precancerous intra epithelial lesions before developing into an invasive form [13,19]. This characteristic associated to the relatively easy diagnosis allows detecting this disease at early stages when treatment results in high cure rates. In addition, the infectious nature of Cervical Cancer etiology makes preventive actions feasible, including vaccination against two HPV types with greater oncogenic risk [20,21,22].

The cervical cancer prevention can be done with primary, secondary and tertiary prevention. The primary prevention is reduced risk factors such as no sexual intercourse at young age, limit sexual partners (monogamous relationship). Primary prevention encompasses the elimination or reduction of exposure to recognized risk factors in susceptible populations to prevent a disease, the health education to promote the use of condoms for sexual intercourse (especially amongst young women), sexual partner reduction and negotiated safer sex strategies have been recommended as a necessary approach to limit the spread of HPV. Primary prevention of cervical cancer also includes HPV vaccine which can prevent HPV type 16 and 18 infection [23,24]. Secondary prevention is the detection and treatment of premalignant lesion before it turns into an invasive cancer [25-27].

The tertiary prevention involves the treatment of confirmed cases of cervical cancer and how to minimize the injury and improve quality of life.

In Malaysia, after more than 50 years of the implementation of Pap smear screening services, the uptake of Pap smear screening in Malaysia remains low. The Second National Health and Morbidity Study reported that only 26 % of eligible women aged over 20 years in Malaysia had undergone Pap smear screening in 2000. This figure rose slightly to 43% as shown by the data which were collected in the Third National Health and Morbidity Survey 2006. The aim of this study was to determine the practice and barriers towards Pap smear test among Malaysian women from a public hospital in Selangor, Malaysia.

Methodology

This study used a cross-sectional, descriptive design. A convenience sample of 142 women aged 18 to 70 years was recruited from the waiting rooms of Obstetrics & Gynaecology ambulatory at Tengku Ampuan Rahimah Hospital, Klang, in Selangor, Malaysia. Data collection started in September 2011 and ended in January 2012. Selfadministered questionnaires were distributed around the waiting area in the clinics during clinic’s hours from 9.00 A.M until 1.00 P.M. They were answered and completed on the spot. The inclusion criteria were female patients who are 18 years old or over and have the ability to speak and understand Malay since the language used in questionnaire were in Malay. On the other hand, the exclusion criteria include women who are younger than 18 and older than 70 years and unable to speak Malay. The proposal of this study was approved by the ethics committee of Management and Science University (MSU). The consent letter was then given to the participant in order to get their permission to be part of this study. The patients were asked if they were willing to complete the survey. If agreed; full explanation on the purpose of the study was given and then consent form was obtained from each participant. The questionnaires consist of 33 questions included socio-demographic such as (age, race, education, occupation, husband’s occupation, family monthly income, marital status, age at marriage, number of partners, and menopause status). The questions also asked about the practiced, barriers and source of information. Data analyzed using the Statistical Package for Social Sciences (SPSS) version 13.0. Descriptive analysis had been done in order to give the view of frequency and percentage. T-test was used in univariate analysis. Multiple linear regression using backward analysis was performed to obtain the final model. The final model was chosen depending on R² and the p value of the model. A p value less than 0.05 are considered significant.

Results

A total number of 142 patients participated in this study, mean age was 31.55 (SD ± 8.17); with age ranging from 18 to 53. The majority of them were younger than 35 years old, Malay, with family monthly income less than 3000 Ringgit Malaysia (RM), with primary and secondary education and single (62%, 68.3%, 64.1%, 73.2%, 88.7%; respectively). The majority of them had heard about Pap smear test (72.5%). Regarding the factors associated with practice of Pap smear test, age, marital status and to have heard about Pap smear influenced significantly the practice of Pap smear test (p=0.001, p=0.001, p=0.001; respectively) (Table 1).

Table 1: Socio-demographic of the participants and factors associated with practice of Pap smear (n=142).

Regarding the practice of Pap smear test; almost half of the study participants (46.5%) reported that having at least one Pap smear in their lifetime. Only 14.8% of them do Pap smear test screening on a yearly basis (Table 2).

Table 2: Practice towards Pap smear test among the study participants (n=142).

Regarding the source of the information, the majority of the participants (57.7%) mentioned that doctors/hospitals/clinics were their sources of information about Pap smear test. Followed by printed media such as newspapers, magazine, books and flyers (43.7%). Then electronic media such as radio and television (31.7%). The lowest source mentioned by the participants was information at workplace (12.7%) (Table 3).

Table 3: Source of information about Pap smear test among the study participants (n=142).

Regarding the reasons for uptake Pap smear test, the highest percentage of the participants (36.9%) mentioned that the reason for uptake Pap test was cervical cancer detection; followed by (30.3%) health purposes. Then the lowest percentage (2.8%) did the Pap smear test because there were medical or self suspicious of cervical cancer (Table 4). Regarding the barriers towards Pap smear test, place of screening (15.5%) was mentioned as the main barrier, followed by don’t have time (11.3%). Then the lower percentages were no female doctor availability, the hospital and the clinic far and the virginity will be taken away (2.1%) (Table 5).

Table 4: Reason for Pap smear screening among the study participants (n=142).

Table 5: Barriers towards Pap smear among the participants (n=142).

In multivariate analysis, only marital status has significantly influenced the practice of Pap smear test among the study participants (Table 6).

Table 6: Multivariate analysis.

Discussion

This survey provides baseline information for planning a cervical cancer prevention programme in Malaysia. In this study the majority of the participants mentioned that their source of information about Pap smear test were healthcare providers. Similar study reported that face to face interaction with clinicians were preferable to audio/visual information [28]. The other source of information was printed media (Newspaper, Magazine, books, flyers), followed by Electronic Media (radio/Television). This may be due to printed materials like magazines and books are not popular sources because of their format, such as length, lack of appeal, and lack of specific information [28]. The same study reported that women stated that magazines and books often contain complex material with medical terminology that is too long and difficult to comprehend and do not reach women of low literacy. Additionally, women placed little trust in the information from television and radio, finding these media commercial and entertaining, but not educational [28]. A study from Qatar showed that the majority women got their knowledge about cervical cancer screening from their social network (relatives and friends) rather than physicians or the media [29]. Few women used Internet (21.8%) as information source about Pap smear test. This may be due to only few women in this study had access to and knowledge of how to use a computer and/or the Internet. Similar data were reported by McCree et al. [28].

It is well known individuals’ knowledge and beliefs about the cause and significance of a particular illness are interconnected with their healthcare-seeking behaviors [30]. Knowledge about Pap smear has significantly influenced the practice of Pap smear screening. Our results are consistent with previous studies [31,32]. A populationbased study of 3197 women in Morelos, Mexico, showed that women who were aware of the purpose of the Pap smear were three times more likely to use screening than women who did not know the purpose [31]. A cross-sectional study carried out in Mexico City reported that women who knew the benefits of Pap smears were six times as likely to participate in screening programs [32]. The findings of this study indicate that in Argentina the lack of knowledge was associated with not being screened; therefore, increasing women’s knowledge about cervical screening may be a key first step of any strategy to increase coverage among women who are under-screened. Similar finding was reported by other studies that women’s knowledge has influenced their screening behavior [33-38]. Therefore there is a need to educate women on the role of HPV in the cause and risk factors of cervical cancer and its prevention. The mass media plays a vital role in this context and its function should be optimized [39]. Other studies support our findings that health education appears to have an important role to play in increasing knowledge and addressing some of the negative biases the young women have against the test [40]. Awareness campaign should be intensified through hospital visits, mass media and public lecture [40]. These results were also supported by a qualitative study among African Americans women which found that demystification of personal beliefs and providing correct information might increase screening rates [41].

In this study, marital status has significantly influenced the practice of Pap test among the study participants. Similar finding was reported by other studies [42,43]. A possible explanation may be due to Pap smear is considered a routine procedure during antenatal care and part of family planning. Another possible explanation is that married women may be more likely to visit a doctor for reproductive health care. Similar study found that Pap smear screening was significantly related to marital status [44]. In another study from Malaysia, Pap smear screening was also significantly associated with marital status [45]. Similar findings were reported by Norwegian female physicians, there was a significant correlation of Pap smear screening and married women [46]. Another study evaluating Korean-American women showed stronger correlation of Pap smear with marital status [47].

In this study, age has significantly influenced the practice of Pap smear among the study participants. Similar findings were reported by several studies [48-59]. Our findings in a previous study among university students that there is a relationship between age and knowledge about cervical cancer screening were confirmed again in this study [39]. Another study also showed that age was associated with knowledge about Pap smear test [60].

The practice of uptake Pap smear test depends on a range of factors that include the healthcare system and its professionals and the women [61]. This study has focused on the practice of Pap smear test from the point of view of women only. It has been estimated that only about 5%– 10% of women in developing countries [62-64] have been screened for cervical cancer with a Pap smear compared to 40%–50% in developed countries [65]. Almost half of the study participants (46.5%) had ever done Pap smear test. Only 14.8% of them do Pap smear test screening on a yearly basis. Higher percentage was reported among Vietnamese- American women (76%) [66]. This study showed a lower percentage of practice of Pap smears when compared to another study from Argentina which reported that 86.8% of the women had ever had the test [42]. One study from Hong Kong reported that the self-reported cervical screening uptake of the 319 interviewed clinic attendees was 47.2% during the previous 12 months [67]. In a Qatar study, almost 40% of the women had had at least one Pap smear [29]. The practice of Pap smear in a study from Kuwait was 23.8% [61].

Several barriers towards Pap smear test were identified in this study; lack of knowledge was the commonest barrier among the participants. In this study the greatest barriers mentioned by the participants was never heard about Pap smear test. That means there is insufficient knowledge about the Pap smear test. The use of the Pap test for cervical cancer screening will not increase unless knowledge is improved and barriers are partially eliminated. Providing information through leaflets and giving clear explanation about the test procedure can help in reducing anticipated distress and embarrassment [61].

The study participants mentioned that male health workers are a barrier to do Pap smear test. This is consistent with other Asian studies which reported women preference for female doctors to perform physical examination on intimate body parts and high embarrassment level with male health providers [35,66]. A study from Mexico also showed that women agreed being examined by a male sample taker would discourage them from getting a Pap smear test [68]. Other similar studies [69-71] reported that the anxiety of potentially being faced with a male sample taker was a significant problem. Another study from Kuwait reported that about 79% of the respondents would prefer a female to conduct the Pap smear test [61]. Similarly; a study from Hong Kong reported that many Hong Kong women did not prefer to have their genital parts examined by a male physician [72]. Lazcano-Ponce et al. [31] reported that being examined by male is one of the barriers of Pap smear test screening among women. Research has shown that easy access to female physician contributed to the increased likelihood of receiving a Pap smear test [35]. The possible explanation may be due to religious affiliation and cultural beliefs, Muslim women in particular felt most comfortable with female health care providers. Several studies reported that the most common reasons in patient who avoid Pap smear are fear of vaginal examination, embarrassment and not concern the risk [73-79].

About 15.5% of the study participants mentioned that lack of information about screening sites is one of the barriers of Pap smear uptake. A similar finding was reported by other studies [39,80]. Higher percentages than this study were reported by Ayinde et al. [40] and Aniebue and Aniebue [81] 16% and 34%; respectively of the study participants had lack of knowledge of centres where the test could be done. The Centres and places of screening should be easily addressed with simple information in order to allow women to know where the test should be done.

Some of this study participants mentioned that pain is one of the barriers towards Pap smear test. Similar studies reported that fear of pain and lacks of hygiene prevent women from attending Pap smear test screening [87,88]. Pain and embarrassment were reported by Lazcano-Ponce et al. [31] as a barrier. Wong et al. [89] reported that an expectation of pain and discomfort during the procedure was another barrier to screening among these women. Misconception about the test being painful have also been reported in other studies [34,76,90]. Fear of infection was reported by others [34,76,90].

In this study, no encouragement from the husband/family/friends was one of the barriers to do Pap smear test. Al-Naggar et al. [39] reported that the least common barrier reported among participants was no encouragement from the partner. A similar finding was reported by Abotchie and Shokar [80] one of the barriers among the study participants was whether their partner would want them to have a Pap smear test. This finding has implications of public health interventions and suggests that broad based public health initiatives will be needed to overcome these barriers [80].

Some of the study participants mentioned that the worry is a barrier for them to uptake Pap smear test. Similar studies reported that fear and anxiety in association with participation in Pap smear screening [39,91]. Fear of discovery of cancer is one of the barriers reported by other studies [34,76,90]. Several studies from other countries [92- 94] also indicate that embarrassment is a major factor that prevents women from performing the Pap test. The concept of embarrassment can be associated with strong cultural factors since majority of women mentioned being shy if they have to expose their private parts and Pap smear test is a very intimate procedure.

This study has limitations on the design and sampling. It was a cross-sectional study. Screening was self-reported data without comparison to any objective medical records and thus the identified factors may be different from those related to the actual cervical screening.

Conclusion

A well-designed health education programme on cervical cancer and benefits of screening would increase the awareness among women. On that issue, a multimedia approach utilizing pictorials, audio-visual and personal communication on cervical cancer could yield beneficial results. One more important point is the fact that better communication with health professionals and improvement of access to health care services should increase the rate of cervical cancer screening. Efforts to increase awareness should target women who are older, unmarried, less educated, and of low income.

Recommendation

The findings of our study suggest that it is important to provide information about the value of cervical smear test and to contradict barriers. Providing information through leaflets and giving clear explanation about the test procedure can help in reducing anticipated psychological distress and embarrassment. Since it is well established that satisfaction is a predictor of compliance, it is important to examine ways of increasing women’s satisfaction with the provided cervical cancer screening service.

Acknowledgements

The author would like to thank the director of Tengku Ampuan Rahimah Hospital, Klang, Selangor, and Head of Department of Obstetrics & Gynecology. I would also to extend my thanks to Diana for collecting the data and to all the patients who voluntarily agreed to participate in this study.

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