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Original Research (Original Article) 


Maithaa Mohammed Ali AlHarfi et al, 2019;3(7):592–596.

International Journal of Medicine in Developing Countries

Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer

Maithaa Mohammed Ali AlHarfi1, Jawaher Khalid Ahmed Aljadidi1, Sayed Ibrahim Ali2, Suha Jafar Al Bahrani2

Correspondence to: Sayed Ibrahim Ali

*College of Medicine, King Faisal University, Al-Hofuf, Saudi Arabia.

Email: drsamas38 [at] gmail.com

Full list of author information is available at the end of the article.

Received: 21 January 2019 | Accepted: 03 March 2019


ABSTRACT

Background:

Cervical cancer is a cancer arising from the cervix. It is caused due to the abnormal growth of cells that have the ability to invade or spread to other parts of the body. Cervical cancer is the second most prevalent cancer worldwide after the breast cancer. An infection caused due to the high-risk strain of the human papilloma virus (HPV) is one of the important risk factors that lead to cervical cancer. The high incidence of cervical cancers attributes the lack of awareness about the disease and its risk factors as well as its prevention methods among the general population. Hence, this study aimed at assessing the knowledge and the awareness level of cervical cancer and its relationship between HPV among women living in the Al-Ahsa region of Saudi Arabia.


Methodology:

A cross-sectional study was carried out among 242 married women aged between 15 and 40 years randomly chosen from Al-Ahsa, Saudi Arabia. The data collection for the study was done using a questionnaire containing the socio-demographic profile of the participants, their knowledge and awareness about the risk factors of cervical cancer, and their attitude toward the risk factors. The collected data were statistically analyzed using statistical package for the social sciences version 21. Chi-square tests and logistic regression models were used for the association analysis. Associations were considered statistically significant at a p-value < 0.05.


Results:

The present study found that the majority of the studied subjects had basic knowledge about cervical cancer, but a very limited of them (31.8%) knew about HPV. Furthermore, a very minor portion of the studied subjects (21.1%) had knowledge about the HPV vaccine and Pap smear test.


Conclusion:

The major cause for a reduced percentage of the knowledge levels regarding the relationship between cervical cancer and HPV among the studied subjects could be attributed to their limited awareness about cervical cancer and its risk factors, and to the inadequate health awareness received regarding its prevention methods. So, stepping up the campaign for the control of cervical cancer, as well as improving the health awareness programs concerning about screening procedures and vaccination available against HPV could create a great impact on the awareness level of women about the association between HPV and cervical cancer.


Keywords:

Human papillomavirus, cervical cancer, awareness.


Introduction

Cervical cancer is the second most prevalent cancer among women worldwide, with an expected 528,000 new cases and 266,000 deaths reported in 2012 [1]. In addition, it is a common type of cancer among women, especially in the age group of 20–40 years [2]. Cervical cancer remains the second cause of cancer-death after the breast cancer, accounting for almost 10% of cancer deaths [3]. Among women belonging to low socio-economic status, as well as rural women, the prevalence and burden of cervical cancer have been reported much higher comparing to their respective counterparts [4]. This high incidence is attributed to a minimum and the inadequate number of screening programs available regarding the disease in these less developed countries [5]. According to the World Health Organization, the risk factors of cervical cancer, include smoking, multiple sexual partners, low socioeconomic status, oral contraception, antioxidant, and vitamin insufficiency in the diet, herpes simplex virus co-infection, human immunodeficiency virus infection, and human papillomavirus (HPV) infection [6]. An infection with a high-risk strain of HPV is considered as the most important risk factor in the development of the cervical cancer [7]. More than 150 types (some sources indicate more than 200 subtypes) of HPV have been recognized. Fifteen (15) of them are classified as high-risk types. Type 16 and 18 are generally reported to cause about 70% of cervical cancer cases. Together with type 31, they are the major risk factors for cervical cancer [8]. One of the few preventable human cancers is cervical cancer; its prevention is based on the early diagnosis of precancerous lesions whose treatment generally makes the development of cancer almost impossible [9]. The incidence and mortality of cervical cancer in the developed countries have decreased significantly because of the efforts made to detect precancerous lesions at a very early stage [10]. Providing widespread and regular cervical screening services for all women who have been sexually active could control and prevent cervical cancer to a larger extent [11]. One of the best methods available is a Pap smear test or the visual inspection of the acetic acid painted cervix (VIA) which is affordable and sensitive compared with other conventional screening methods available [12]. Also, vaccination against the HPV in women before the onset of sexual activity prevents the disease [13]. The one-visit approach, which involves the screening of cervical cancer with VIA by trained personnel and provision of cryotherapy for obvious mild-to-moderate cervical dysplasia, is highly recommended in the developed countries [14].

Screening methods and policies providing information on the prevention of cervical cancer are different worldwide. The assumption can be made that women’s poor knowledge of carcinogenic and cancer risk factors is the cause of poor cervical cancer diagnosis in most of the countries since the competency of the programs vary in many countries although similar methods are used [14]. The aim of the current study was to assess the knowledge and awareness regarding the relationship between HPV and cervical cancer among married women aged between 20 and 40 years living in Al-Ahsa, Saudi Arabia of the relationship between HPV and cervical cancer.


Subjects and Methods

A cross-sectional study was carried out among 242 married women aged between 15 and 40 years randomly chosen from Al-Ahsa, Saudi Arabia. Al-Ahsa is one of the largest governorates in Saudi Arabia’s Eastern Province, the general population of women is 429,911, and the projected population of women aged 15–40 years old is about 107,428. The sample size was calculated using the following formulae for estimating prevalence in a descriptive study where the study population is more than 107,428:

sample size = z2 × p (1 − p) e21 + z2 × p (1 − p) e2N

Population size = N|Margin of error = e| z-score = z

where e is percentage, put into decimal form (for example, 3% = 0.03).

An online self-administered structured questionnaire was designed based on the study objectives with the help of previous literature and studies available on the same topic. The questionnaire contained close-ended questions to assess the level of awareness and knowledge of cervical cancer and its risk factors. The questionnaire was divided into three sections. The first section dealt with the socio-demographic profile of the subjects (e.g., age, sex, education, etc.), the second had questions regarding the knowledge and awareness about cervical cancer and its risk factors, especially HPV, and the third section covered the attitude of respondents toward the risk factors. This questionnaire was employed for the data collected from the randomly employed study subjects. The study was conducted for a period of 4 months. The collected data were statistically analyzed using Statistical Package for the Social Sciences version 21. Descriptive statistics including mean and standard deviation (SD) were used. A p-value of less than 0.05 was considered significant. Participants who answered 60% of the questions correctly were considered to be “aware”. Percentages and proportions were calculated for all the variables, and relevant tables and graphs were computed. Ethical approval to carry out the study was taken from King Faisal University ethical review committee. Only those participants who gave their personal online consent were allowed to participate in the study. The identities of the participants were kept confidential.


Result

Two hundred and forty-two women were approached for this study. The mean age of the study subjects was 27.5 (SD 12.5). Among the total subjects, 125 (51.6%) were married, and 117 (48.3%) were single. Figure 1 shows the education level of the studied participants. The majority of the study subjects were students or working women (70.1%), while the rest of them were unemployed (29.9%). Only 29.21% of the study subjects could be considered to be “aware“ about the relationship between cervical cancer and HPV as an etiological factor. Among all the age groups studied, awareness regarding cervical cancer, HPV, and vaccination available was found higher in women aged between 20 and 25 years. Awareness was also found higher among college students. The sources of the information for the studied subjects regarding cervical cancer and HPV are shown in Table 1. Among the total subjects, only 77 (31.8%) had prior knowledge that HPV is a causative factor of cervical cancer. A limited number of subjects, 51 (21.1%) had prior knowledge about the HPV vaccine, and only 5 of the study subjects (2.1%) had knowledge about vaccine available for cervical cancer prevention. Most of the participants were willing to receive the HPV vaccine (61.7 %), while 38.3% of them rejected the idea of getting the vaccine. Regarding the Pap smear test, 134 of the study subjects (55.4%) had at least heard about it. The attitude of the total participant study subjects toward the Pap smear test is shown in Figure 2.

Figure 1. Level of education among the study subjects.

Table 1. Source of participants’ information.

Source of information Percent
Study field 31%
Friends and relative 11.6%
TV and newspapers 7.9%
Social media 26.4%
others 23.1%

Figure 2. Attitude of the total study subjects toward Pap smear test.


Discussion

Cervical cancer is the second most common cancer among women worldwide [15] and among the top 12 most common cancers in women in the Kingdom of Saudi Arabia] 16[. About 89% of cervical cancers in Saudi Arabia were associated with HPV infection, while 78.7% of HPV-positive tumors were infected with HPV-16/18 [17,18]. Cervical cancer is a preventable disease, and a key aspect of its prevention is the detection of the premalignant lesion by cervical screening [19]. Lack of knowledge about cervical cancer in the general population and among healthcare workers is a prime barrier for access to cervical cancer prevention [20]. The present study showed that only 29.21% of the participating women could be considered aware of the relationship between cervical cancer and HPV as an etiological factor. Only 77 (31.8%) of the total 242 women knew that HPV is a causative factor of cervical cancer. A study done in Riyadh, Saudi Arabia showed that the awareness of HPV was significantly low; only 34.5% participants were aware, and (27.4%) were aware of its relation with cervical cancer [21]. Similar results were observed in the study done in Jeddah, Saudi Arabia (2009) which showed that 85.6% of the women were not aware of HPV as a risk factor for cervical cancer [22]. In comparison, a higher level of awareness about cervical cancer was shown in studies done in Malaysia (88.8%) [23] and Kenya (87%) [24]. Cervical cancer mortality can be reduced up to two-thirds by ensuring that all women are vaccinated with long-term protection. In addition, the vaccines can reduce the health care burden and associated sequelae [25]. Low level of awareness about the availability of such a vaccine for cervical cancer is mostly associated with a low percentage of vaccinated women. Across the studied sample, only 51 of them (21.1%) ever heard about the HPV vaccine, and only 5 respondents (2.1%) received the vaccine. A study was done in Mecca, Saudi Arabia (2012) showed a similar result that only 20.8% of the study group did know the existence of the HPV vaccine and only 1.4% of the study group received the vaccine [26]. Another study was done in Riyadh, Saudi Arabia showed a higher percentage of awareness, where (32.3%) participants were aware of the ability of the HPV vaccine to prevent cervical cancer and other HPV-related diseases [21]. Also, a higher level of awareness was reported in a study conducted in Hungary, which reported that (35%) of the population have heard about the vaccine [27]. Although the proportion of participants in the present study who had knowledge of the HPV vaccine was low, the majority of participants (61.7 %) consented to initiate the HPV vaccine series.

The reduced percentage regarding the knowledge levels of participants about HPV and its vaccine could be attributed to their limited awareness about cervical cancer and its risk factors. The reason for the low level of awareness about preventive measures may be also due to the inadequate health awareness about prevention or because of lack of availability of screening services and vaccination against HPV in the studied region. Awareness of cervical cancer, HPV, and its vaccine among the participant in the present study was higher among the college students. Similar results were observed in Kuwait, the United Arab Emirates (UAE), and Ghana where adequate knowledge was significantly higher among women whose education level was above-secondary school [28,29]. Most of the participated women (31%) responded that the sources of information were their study field followed by social media (26.4%). However, the Number of studies done in Jeddah [22], Mecca [26], and Turkey [30] showed that mass media is the main source of the information. In the present study, the main source of information was the study field as most of the participants were college students. This study further sought to find out if the respondents knew about the Pap smear test or not. Among the study subjects, 134 of the sampled women (55.4%) heard about Pap smear and only 27 (11.3%) of the respondents had ever had about a Pap smear test. These values were slightly less when compared with the results reported among women in Jeddah, Saudi Arabia where (67.6%) of the respondents were aware of the Pap smear; however, only (16.8%) had undergone the test [22]. In comparison, Kuwait and Iran showed higher awareness where 76.9% and 76% of the studied subjects, respectively, heard about the Pap test and 35.2% and 36%, respectively had undergone a Pap smear test [28,31]. But, it is noted that this level of awareness was higher than that had been reported among Nigerians (38%) [32] and Indians (11.6%) [33]. The findings support the clear need for Saudi women to be provided with more information, education, and awareness of HPV infection and its link to cervical cancer to improve HPV vaccination rates. In addition, women need to be educated about the benefits of cervical cancer screening. Health education, counseling, outreach programs, and community-based interventions are needed to improve the uptake of the Pap smear.


Conclusion

This study highlighted the low level of knowledge and awareness about the relationship between cervical cancer and HPV that might be contributed to the fact the cervical cancer is less common in Islamic country due to the controlled sexual practices. In order to step up the campaign for the control of cervical cancer in Al-Ahsa, it is, therefore, very important to concentrate much of the effort on the creation of awareness and enhancing the knowledge of women about cervical cancer and screening. These could be done through awareness campaigns that could be conducted in public areas where women participation is high. It could also include awareness lectures about HPV and cervical cancer that could be conducted at schools and colleges. It is also important to improve health awareness about screening services and vaccination available against HPV in the general public.


List of abbreviations

HPV Human papilloma virus
SD Standard deviation
SPSS Statistical package for the social sciences
UAE United Arab Emirates
VIA Visual inspection of the acetic acid painted cervix

Conflict of interest

The authors declare that there is no conflict of interest regarding the publication of this article.


Funding

None.


Consent for publication

Informed consent was obtained from all the participants.


Ethical approval

Ethical approval to carry out the study was taken from King Faisal University Ethics Review Committee in College of Medicine via Ref: 10-31-3, year 2018.


Author details

Maithaa Mohammed Ali AlHarfi1, Jawaher Khalid Ahmed Aljadidi1, Sayed Ibrahim Ali2, Suha Jafar Al Bahrani2

  1. College of Medicine, King Faisal University, Alhufof, Saudi Arabia
  2. Department of Family and Community Medicine, College of Medicine, King Faisal University, Alhufof, Saudi Arabia

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How to Cite this Article
Pubmed Style

AlHarfi MMA, Aljadidi JKA, Ali SI, Bahrani SJA. Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. IJMDC. 2019; 3(7): 592-596. doi:10.24911/IJMDC.51-1548091380


Web Style

AlHarfi MMA, Aljadidi JKA, Ali SI, Bahrani SJA. Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. http://www.ijmdc.com/?mno=27331 [Access: May 27, 2019]. doi:10.24911/IJMDC.51-1548091380


AMA (American Medical Association) Style

AlHarfi MMA, Aljadidi JKA, Ali SI, Bahrani SJA. Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. IJMDC. 2019; 3(7): 592-596. doi:10.24911/IJMDC.51-1548091380



Vancouver/ICMJE Style

AlHarfi MMA, Aljadidi JKA, Ali SI, Bahrani SJA. Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. IJMDC. (2019), [cited May 27, 2019]; 3(7): 592-596. doi:10.24911/IJMDC.51-1548091380



Harvard Style

AlHarfi, M. M. A., Aljadidi, . J. K. A., Ali, . S. I. & Bahrani, . S. J. A. (2019) Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. IJMDC, 3 (7), 592-596. doi:10.24911/IJMDC.51-1548091380



Turabian Style

AlHarfi, Maithaa Mohammed Ali, Jawaher Khalid Ahmed Aljadidi, Sayed Ibrahim Ali, and Suha Jafar Al Bahrani. 2019. Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. International Journal of Medicine in Developing Countries, 3 (7), 592-596. doi:10.24911/IJMDC.51-1548091380



Chicago Style

AlHarfi, Maithaa Mohammed Ali, Jawaher Khalid Ahmed Aljadidi, Sayed Ibrahim Ali, and Suha Jafar Al Bahrani. "Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.." International Journal of Medicine in Developing Countries 3 (2019), 592-596. doi:10.24911/IJMDC.51-1548091380



MLA (The Modern Language Association) Style

AlHarfi, Maithaa Mohammed Ali, Jawaher Khalid Ahmed Aljadidi, Sayed Ibrahim Ali, and Suha Jafar Al Bahrani. "Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.." International Journal of Medicine in Developing Countries 3.7 (2019), 592-596. Print. doi:10.24911/IJMDC.51-1548091380



APA (American Psychological Association) Style

AlHarfi, M. M. A., Aljadidi, . J. K. A., Ali, . S. I. & Bahrani, . S. J. A. (2019) Awareness level of women living in Al-Ahsa, Saudi Arabia about the relationship between human papillomavirus and cervical cancer.. International Journal of Medicine in Developing Countries, 3 (7), 592-596. doi:10.24911/IJMDC.51-1548091380