Awareness and Attitude to the Risk of Cervical Cancer and Screening Method Among Women in the Najran Region of Southern Saudi Arabia

Introduction:The aim of this study was determined the level of awareness among women regarding risk factors for cervical cancer and screening methods, their sources of information, and general attitudes toward Pap smear screening tests and human papilloma virus vaccination. Method:A cross-sectional interviewer administered an electronic questionnaire among women in Najran City during the period from March 1, 2019 to June 30, 2019. The data were analyzed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. Result: A total of 3,387 women participated in this study and the response rate was 100%. Less than 10% of the participants had good awareness and 70% had poor awareness about the risk factors for cervical cancer. In terms of the major barriers to taking the Pap smear test among married women, 968 (56.7%) had no knowledge of the test and 338 (19.85%) considered it unnecessary. Signicant predictors of the level of awareness about cervical cancer and Pap smear testing were identied as the age of women, occupation, family history of cancer, monthly income (P < 0.001) and education level (P = 0.003). Conclusion: we detected a lack of awareness about risk factors for cervical cancer and the benets of early detection among women in this region. Healthcare providers should implement policies or programs for cervical cancer screening and vaccination throughout all primary healthcare centers. Chi-squared tests/Monte Carlo exact tests and Fisher’s exact tests were used to evaluate associations between sample characteristics and knowledge level. Two-tailed tests were used for statistical analyses, with an alpha error of 0.05. P-values >0.05 were considered to indicate statistical signicance. Correct and incorrect answers were assigned scores of one point or zero points, respectively, and the discrete scores for the different knowledge domains were summed. Awareness scores presented as a percentage of the maximum were as follows: 50%–75%,

A relatively low prevalence of abnormal smears and cervical cancer has been reported in Muslim countries compared to that in Western populations. Probable explanations for this difference include sexual behavior under Islamic rules [5].
Studies conducted in Saudi Arabia showed that 89% of cervical cancers were associated with HPV infection, with 78.7% of HPV-positive tumors infected with HPV-16/18. These strains caused the cancer to appear 5 years earlier than the combined HPV-negative and other HPV genotypes [6]. The Papanicolaou (Pap) smear screening test decreases the incidence mortality of cervical cancer [7]; however, no program of such testing has been implemented in the healthcare sector in Saudi Arabia.
The World Health Organization (WHO) demonstrate that education of the target population combined with the availability of a screening program and treatment in the early stages of invasive cancer of the cervix, has an important effect in reducing the morbidity and mortality from the disease. It is important that the educational programs are designed with consideration for the culture of the country, and that the myths that tend to be prevalent about cancer are addressed.
The aim of this study was to determine the level of awareness regarding risk factors for cervical cancer and screening methods among women in the Najran region of southern Saudi Arabia, their sources of information, and their general attitudes toward Pap smear testing and HPV vaccination.

Methods:
We conducted a cross-sectional interviewer administered study among women in Najran City Saudi Arabia during the period from March 1, 2019 to June 30, 2019. The study took place in a girls' school, a Maternity and Children's Hospital, King Khalid Hospital and Najran University in Najran City, Saudi Arabia. All females who agreed to participate in the study were included by verbal concent through answerd the questionnior in front of data collectors; no exclusion criteria were applied. The sample size we included all the participant who agreed during this period a total of 3,387 participants. This study received ethics approval from the Research Committee of the College of Medicine, Najran University and the Research Committee of the General Directorate of Health Affairs Najran IRB log Number: 2019-008E. All data were collected through direct interviews using an electronic questionnaire.
The data were analyzed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp.
Chi-squared tests/Monte Carlo exact tests and Fisher's exact tests were used to evaluate associations between sample characteristics and knowledge level. Two-tailed tests were used for statistical analyses, with an alpha error of 0.05. P-values >0.05 were considered to indicate statistical signi cance. Correct and incorrect answers were assigned scores of one point or zero points, respectively, and the discrete scores for the different knowledge domains were summed. Awareness scores presented as a percentage of the maximum score were categorized as follows: "poor" <50%, "moderate" 50%-75%, and "good" >75%.
The researcher used a self-administered questionnaire designed to obtain the following information: 1) sociodemographic data, including age, nationality, educational level, occupation, marital status, medical history and monthly income; 2) knowledge of risk factors for cervical cancer and screening methods; and 3) attitude and barriers to screening of cervical cancer.

Results:
The total of 3,387 women and girls participated in this study.The sociodemographic characteristics of the participants are shown in Table 1. Among the participants, 50.5% were in the 18-29 years age range and 94.8% were Saudis. In total, 40.9% of the participants did not work and 20.8% were school teachers. In addition, 70.4% of the participants were educated to university level and above. Furthermore, 47.5% of participants had a monthly income of less than 5,000 Saudi Riyals. Among the participants, 5.6% and 2.8% were suffering from diabetes mellitus and hypertension, respectively, and 21.7 % had family history of any type of cancer.
Details of the awareness scores of the participants regarding risk factors for cervical cancer are shown in Figure 1. Less than 10% of the participants had good awareness about the risk factors for cervical cancer, 20% had moderate awareness and 70% had poor awareness.
Details of the awareness and attitude of married women to Pap smear testing are shown in Table 2.
Among 1,990 participants who were married, divorced and widowed, 1,024 (51.5%) were aware of Pap smear testing, but only 282 (14.2) had actually been screened, and of these, 197 (69.9%) had been advised to do so by doctors. In terms of the major barriers to taking the Pap smear test among married women, 968 (56.7%) had no awareness of the test and 338 (19.85%) considered it unnecessary.
Details of the awareness and attitude of participants about vaccination against cervical cancer are shown in Table 3. Among the participants, 2,983 (88.1%) considered that cervical cancer can be prevented by vaccination, but only 530 (14.8%) had been vaccinated and had done so on the advice of a physician, social media or friends and family.
The distribution of predictors of the general awareness scores of cervical cancer is shown in Table 4. Signi cant predictors of the level of awareness about cervical cancer and Pap smear testing were identi ed as the age of women, occupation, family history of cancer, monthly income (P < 0.001) and education level (P = 0.003).

Discussion:
Cervical cancer is a major public health problem throughout the world. Cervical cancer is the forth most common cancer in women worldwide [8]. The Pap smear it can decrease the incidence of cervical cancer due to early detection. Good awareness about Pap smear screening and the risk factors for cervical cancer decrease the associated mortality and morbidity. In the present study, we show low percentage of the participants were aware to risk factors for cervical cancer and more than half of married women were aware of Pap smear testing, although few of them had been screened. In total, a third of participants were aware that HPV is a cause of cervical cancer. A study conducted in Jeddah, Saudi Arabia, showed that low percentage of women were aware of the link between HPV and cervical cancer [9]. A similar study conducted in Riyadh showed that a third of participants were aware of HPV and 27.4% were aware of its relationship within cervical cancer [10]. Furthermore, in a study conducted in Tanzania, less than half of the nurses who participated had adequate awareness regarding cervical cancer [11]. In comparison, a study conducted in Saudi Arabia showed a good overall knowledge level about cervical cancer (78.6%), although the knowledge regarding HPV (16.4%) was low [12]. A similar study conducted in Malaysia (88.8%) revealed a high level of knowledge about cervical cancer [13].
Among the married participants, approximately half were aware of the Pap smear test, but only 14.2% had been screened. Of the participants tested, 69.9% did so on the advice of a physician. In total, 56.7% of the participants had no awareness of the screening test and 18.9% considered it unnecessary. In a similar study conducted in Jeddah, 67.6% of participants were aware of the Pap smear test, but only 16.8% had been screened, mainly due to lack of awareness [9]. In comparison, a study in Eastern Nigeria revealed that 41.5% of participants were aware of the Pap smear test but, only 20.5% had been screened, with most of these participants considering the test to be unnecessary [14]. Also, another study in Al-Ahsa showed that 55.4% of participants were aware of the Pap smear test, but only 11.2% had been screened [15]. Participants in this study also reported pain and fear of results as reasons for not being screened.
These ndings are consistent with another study in which fear was reported as a barrier to screening [16].
Vaccination against HPV decreases the morbidity and mortality of cervical cancer. Therefore, a high level of awareness about cervical cancer may result in increased uptake of screening and the implementation of such preventive strategies. Our study showed that 88.1% of participants accepted that cervical cancer is preventable, of which 57.2% were aware of the availability of a vaccine, although only 14.8% had been vaccinated on the advice of a physician or social media. In comparison with other studies in Saudi Arabia, only 20.8% of participants in a study conducted in Mecca were aware of the HPV vaccine and only 1.4% had actually been vaccinated [17]. Moreover, in the study in Al-Ahsa, only 21.1% of participants were aware of the HPV vaccine, and only 2.1% had received the vaccine [15].
Multiple logistic regression analyses in our study showed that age, education level, occupation, family history and monthly income had a signi cant effect on awareness of risk factors for cervical cancer, Pap smear testing and vaccination. The ages of the participants with good awareness of cervical cancer age ranged from 30 to 39 years. Also, in terms of occupation, the participants working in healthcare or in the medical eld had good awareness. Furthermore, participants with a family history of cancer and monthly income exceeding 15,000 SR had a good knowledge .
The nding of our study highlight the need to educate women about risk factors for cervical cancer and the bene ts of preventive measures such as Pap smear testing and vaccination. Such strategies will be important in increasing the uptake of Pap smear screening and vaccination. Implementation of screening and vaccination programs delivered through schools, universities, healthcare providers, social media and home visiting will improve the awareness of cervical cancer.

Conclusion:
This study demonstrates a lack of awareness about the risk factors for cervical cancer and the bene ts of early detection. Healthcare providers should implement policies or programs for cervical cancer screening and vaccination throughout all primary healthcare centers to encourage participation. Such programs require the cooperation of multidisciplinary teams of physician, nurses' educators and psychologists to explain the bene ts of screening and early management of cervical cancer.

Declarations
This study received ethics approval from the Research Committee of the College of Medicine, Najran University and the Research Committee of the General Directorate of Health Affairs Najran IRB log Number: 2019-008E. All participants in this study will remain anonymous.
Availability of data and material:

Available
Competing interests: The authors declares that they have no competing interests.

Funding:
Self-funding by researchers.
[16] Anttila A, Ronco G. Description of the national situation of cervical cancer screening in the member states of the European Union. Eur J Cancer 2009; 45: 2685-708.     Availabilityofdataandmaterial.xlsx