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Original Research 


Shatha Abdulaziz Alammar et al, 2018;2(3):97–102.

International Journal of Medicine in Developing Countries

Awareness of cervical cancer and its prevention among high school female teachers in Riyadh

Shatha Abdulaziz Alammar1*, Nouf Saleh Al-salloum2, Tarek Elsaid3

Correspondence to: Shatha Abdulaziz Al Ammar

*King Abdullah University Hospital, Riyadh, Saudi Arabia.

Email: dr.shatha.alammar@gmail.com

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

Received: 14 May 2018 | Accepted: 20 September 2018


ABSTRACT

Background:

Cervical cancer is one of the most common types of female cancers in the world. In Saudi Arabia, few studies examined the awareness about cervical cancer and its screening, and it was found to be lower than seen in other developed countries.


Methodology:

A cross-sectional study was conducted through a questionnaire and population was selected through a multistage stratified random sample of 450 government girls’ high school teachers in Riyadh in November 2014.


Results:

The overall relative score (% of correct answers) was 43.4%. Similarly, the percentage of correct answers was 27% in burden questions, 50.8% in risk factor questions, 35.4% in warning symptom questions, and 53.3% in prevention questions. Teacher education, age, and the number of children showed a trend of significant association with level of awareness (p = 0.007, p = 0.059, and p = 0.058, respectively). However, in multivariate linear regression, education was the only significant independent predictor of higher awareness (p < 0.001).


Conclusion:

The overall awareness of cervical cancer and its prevention among high school female teachers in Riyadh was relatively low. This was similar to the figures from developing countries but much lower than seen in developed countries. The finding may indicate the need to start national education programs to increase the knowledge and prevention of cervical cancer among female teachers.


Keywords:

Cervical cancer, prevention, high school female teachers, Riyadh.

Introduction

Cervical cancer is one of the most common types of female cancers worldwide and is only preceded by breast cancer. Since cervical cancer is strongly linked to human Papillomavirus, the cancer is greatly preventable. Early recognition of abnormal cytological changes in the cervix is critical to stop the progression of the disease [1].

The World Health Organization estimated that cervical cancer was the second most common cancer among females between the age of 15 and 44 years worldwide in 2012 [2,3]. Approximately 530,000 new cases occur every year and 270,000 women die from cervical cancer [2]. Smoking women are twice at risk of developing cervical cancer as compared to non-smokers [4].

The awareness about cervical cancer among Saudi women is generally lower than seen in developed countries as Saudi Arabia has lower risk than seen in many parts of the world [5]. A recent cross-sectional study among medical students in Al-Hasa showed a high percentage of unawareness about early warning symptoms (44%) and risk factors (42%) of cervical cancer [6]. Additionally in another Saudi study more than half of the female students were unaware of the Papanicolaou (PAP) test as a screening tool, and a vast majority (90%) were unaware of the availability of the vaccine against human papillomavirus (HPV) [7].

Methods

A cross-sectional study was conducted through a questionnaire of 450 high school government teachers in Riyadh in the month of November 2014.

The structured questionnaire was developed by the researcher and piloted 20 female teachers who volunteered.

All categorical variables were presented as frequencies and percentages while continuous variables were presented as means and standard deviations. An overall score and sub-scores were created from the awareness questions. A point was given for the correct answer and a zero was given for the incorrect answer. The questions used in creating the score were two burden questions, 11 risk factor questions, 10 warning symptom questions, and seven prevention questions. The relative score was obtained by dividing the actual correct answers by potential correct answers and expressed as a percentage. To detect significant differences in demographic and occupational characteristics between the tertiles of overall awareness score, chi-square, or Fisher’s exact test, as appropriate, were used. All p-values were two-tailed. p-value < 0.05 was considered as significant. SPSS software (release 16.0, SPSS Inc., Chicago, IL) was used for all statistical analysis.

Results

Out of the total 558 teachers who initially completed the study questionnaires, 108 (19.4%) questionnaires were excluded due to incomplete answers. This left a total of 450 teachers who were included in the current analysis. The demographic characteristics of the included teachers are shown in Table 1.

Approximately 31.5% of the teachers were taking one or more medications. The most frequently used medications were medications for treatment of thyroid disease (6.4%), followed by asthma (3.9%), hypertension (3.4%), diabetes (3.4%), hyperlipidemia (3.0%), contraception (2.5%), vitamin D deficiency (2.3%), gastrointestinal disease (1.8%), and other diseases (8.7%).

Almost two-fifths of the teachers had been working for 11–20 years whereas the rest were either working for 10 years or less (36.3%) or more than 20 years (23.4%). More than half (51.9%) of the teachers were specialized in social sciences such as Islamic studies, English and Arabic languages, geography, history, art, and domestic economy. Approximately 22% of the teachers were specialized in natural sciences mathematics, science, biology, chemistry, physics, and information systems. The rest of the teachers (26.2%) reported general, unspecified, or other specialties.

The level of awareness about cervical cancer burden, risk factors, and symptoms was shown in Table 2. The most frequently identified risk factor of cervical cancer by the study subjects was weakened immunity (70%); on the other hand, the least frequently identified risk factor of cervical cancer was multiple deliveries (13%). The most frequently identified symptom of cervical cancer was post-menopausal bleeding (57.1%).

Table 1. Demographic characteristics of the study teachers.

Characteristics Number Percentage
Age group
<25 10 2.2
25–34 150 33.3
35–44 192 42.7
45–54 78 17.4
≥55 20 4.4
Nationality
Saudi 436 96.9
Non-Saudi 14 3.1
Education
Diploma 59 13.1
Bachelor 353 78.4
Master 21 4.6
PhD 17 3.9
Marital status
Single 25 5.7
Married 387 86
Divorced 26 5.7
Widow 12 2.6
Number of children
<4 164 41.1
≥4 235 58.9
Residence type
Own house 285 63.3
Own apartment 29 6.4
Rent house 66 14.5
Rent apartment 70 15.8
Smoking status
Current 43 9.6
Previous 16 3.7
Never 391 86.7

The scores of cervical cancer awareness among the studied teachers are shown in Table 3. The overall score ranged between 0 and 25 with an average of 11.22. The burden sub-score ranged between 0 and 2 with an average of 0.54. The Risk factor sub-score ranged between 0 and 11, with an average of 5.50. The symptoms sub-score ranged between 0 and 10 with an average of 3.53. The prevention sub-score ranged between 0 and 7 with an average of 1.65. Out of the maximum expected, the overall relative score represented 43.4% correct answers. Similarly, the percentage of correct answers (relative scores) were 53.3% for prevention questions, 50.8% for risk factor questions, 35.4% for symptom questions, and 27% for burden questions.

The associations between the demographic characteristics of the study teachers and the tertiles of the overall score of cervical cancer awareness are shown in Table 4. The difference was highly significant (p = 0.007).

The associations between occupational characteristics of the study subjects and the tertiles of the overall score of cervical cancer awareness are shown in Table 5. Although there was a small increase in the level of awareness by increasing the duration of work, the difference was not significant (p = 0.853). Additionally, there was no significant association between the teacher specialty and the level of awareness.

Table 2. Awareness about the burden, risk factors, symptoms, and prevention of cervical cancer among the study teachers.

Total No Yes Don’t know
N N % N % N %
Awareness about burden
Occurrence within female cancers 450 69 15.3 178 39.5 203 45.2
Mortality within female cancers 450 64 14.2 62 13.7 324 72.1
Awareness of risk factors
Smoking 450 97 21.5 258 57.3 95 21.1
Weakened immunity 450 70 15.5 321 71.3 59 13.2
Prolonged use of OCP 450 91 20 273 60.6 86 19.4
Repeated vaginal infections 450 65 14.4 322 72.4 63 14.2
Early marriage (before 17 years) 450 287 65.3 72 16 91 20.7
Multiple deliveries 450 309 68.6 58 13.0 83 18.4
STD infection from husband 450 115 25.6 250 55.6 85 18.8
Aging 450 170 37.7 184 41.1 96 21.2
Nulliparity 450 248 55.3 89 19.7 113 25
Family history of cervical cancer 450 74 16.4 289 64.5 87 19.1
HPV infection 450 68 15.5 194 44.1 178 40.5
Awareness about symptoms
Vaginal bleeding between periods 450 161 35.9 194 43 95 21.1
Persistent low back pain 450 177 39.4 168 37.3 105 23.3
Persistent foul vaginal discharges 450 136 30.3 215 47.7 99 22
Pain during sex 450 175 38.9 163 36.3 112 24.8
Heavy or prolonged periods 450 190 42.3 147 32.6 113 25.1
Chronic constipation 450 275 61.2 45 10 130 28.8
Post-menopausal bleeding 450 81 18 257 57.1 112 24.9
Bleeding during or after sex 450 152 33.7 156 34.8 142 31.5
Blood in urine or stool 450 236 52.4 103 23 111 24.6
Unexplained loss of weight 450 184 40.8 147 32.7 119 26.5

STD, sexually transmitted disease.

Table 3. Total score and sub-scores of cervical cancer awareness among the study teachers.

Minimum Maximum Mean Standard deviation
Burden 0 2 0.54 0.68
Risk factors 0 11 5.50 2.30
Symptoms 0 10 3.53 2.66
Prevention 0 7 1.65 1.51
Total score 0 25 11.22 4.97

Table 4. Frequency of correct answers to cervical cancer awareness questions relative to the number of questions asked in the study teachers by the tertiles of total awareness score.

Lowest (%) Middle (%) Highest (%) Total (%)
Burden 12% 26 41 27
Risk factors 31 52 68 51
Symptoms 10 33 61 35
Prevention 26 54 69 53

When teacher’s education, age, and number of children (which were either significantly associated or showed a trend of significant association with awareness) were analyzed using a multivariate linear regression, education was the only significant independent predictor of higher total cervical cancer awareness score (p < 0.001) with adjusted mean awareness scores increasing from 9.20 with diploma, to 12.12 with Bachelor degree, and 13.78 with master or PhD degree. On the other hand, age and number of children were insignificant (p = 0.460 and p = 0.352, respectively).

Table 5. Demographic characteristics of the study teachers by the levels (tertiles) of the cervical cancer awareness.

Lowest Middle Highest p-value
N % N % N %
Age group
<25 6 60.0 2 20.0 2 20.0 0.117
25–34 41 27.3 62 41.3 47 31.3
35–44 57 29.7 68 35.4 67 34.9
45–54 29 37.2 24 30.8 25 32.1
≥55 6 30 4 20 10 50
Age group
<25 6 60.0 2 20.0 2 20.0 0.059
35–54 127 30.2 154 36.7 139 33.1
≥55 6 30 4 20 10 50
Nationality
Saudi 132 30.3 153 35.1 151 34.6 0.272
Non-Saudi 1 7.2 3 21.4 10 71.4
Education
Diploma 29 49.2 18 30.5 12 20.3 0.007
Bachelor 99 28.0 124 35.1 130 36.8
Master/PhD 5 23.9 12 57.1 4 19
Marital status
Single 10 40.0 10 40.0 5 20.0 0.343
Married 117 30.2 138 35.7 132 34.1
Divorced or widow 13 34.2 15 39.4 10 26.1
Number of children
<4 38 23.2 68 41.5 58 35.4 0.058
≥4 79 33.6 77 32.8 79 33.6
Residence type
Own house 86 30.2 105 36.8 94 33.0 0.509
Own apartment 7 24.1 8 27.6 14 48.3
Rent house 29 43.9 18 27.4 19 28.7
Rent apartment 20 28.6 28 40.0 22 31.4
Smoking status
Current 11 25.6 19 44.2 13 30.2 0.891
Previous 5 31.2 5 31.2 6 37.6
Never 122 31.2 139 35.5 130 33.2

Discussion

The current study showed an overall awareness rate of 43% among high school female teachers in Riyadh. The awareness was relatively better for risk factors and prevention (51% and 53%, respectively) and somewhat lower in the burden and early warning symptoms (27% and 35%, respectively). A higher level of awareness was associated with the higher educational level of the teacher, being highest among those who had Bachelor degree as well as master or Ph.D. degree (36.8% and 34.6%, respectively) and lowest among those who had a diploma (20.3%). The difference was statistically significant (p = 0.007). In addition, the high level of awareness was associated with increasing age of the teacher, being highest among those aged ≥55 years (58.8%), lower number of children (<4 children) (35.4%) and lowest among those aged <25 years (20.0%) and those with higher number of children (>4 children) (33.6%). However, these did not reach statistical significance. The low overall awareness of cervical cancer and its prevention in the current study is similar to the figures from developing countries but much lower than seen in developed countries [810].

In a recent study among female students who were studying one of the health-related disciplines in Riyadh, the awareness about early warning symptoms, risk factors, and prevention of cervical cancer was generally below 50% for the majority of the questions [7]. Comparing these findings to the current study showed that the sample population belonged to health-related colleges who were probably exposed to more health education information than do regular college students or typical Saudi female in their age.

Sait [11] reported that only 14% of the women were aware of HPV infection as the cause of cervical cancer and only 10% of these women were aware of the availability of the vaccine against HPV. On the other hand, approximately two-thirds of the women were aware of the PAP test as a screening tool [11]. The awareness of the screening test might have come from non-Saudi subjects who knew of the screening from their home countries. Interestingly, the majority (82%) of the current study teachers were aware of the PAP test as a screening method for cervical cancer, but the majority (78%) were not aware of the availability of HPV vaccine, this goes in line with several studies in Saudi Arabia [7,11] and outside Saudi Arabia [8,12].

Education in the current study was the only independent factor that was associated with better awareness. Similar findings have been reported in previous studies that assessed the association between awareness level and the educational status. A cross-sectional study among women attending gynecology clinics in Nigeria found a significant association between the educational status and the knowledge of the cervical smear PAP test [13].

The weak association between the level of awareness and age and the number of children (shown in the univariate analysis) disappeared in multivariate analysis. This may indicate that both variables confound the association between education and the level of awareness. A separate sub-analysis of the current data showed that those with better education had lower age and lower number of children.

Future studies should focus on acceptance of HPV vaccination and PAP test screening as well as the best educational method that increase the awareness and screening uptake.

Conclusion

The overall awareness of cervical cancer and its prevention among high school female teachers in Riyadh is relatively low. The higher level of education was associated with a higher level of knowledge. The awareness was relatively better for risk factors and prevention and somewhat lower in the burden and early warning symptoms. The current finding was similar to the figures from developing countries but much lower than seen in developed countries.

Acknowledgment

None.


List of abbreviations

HPV Human papillomavirus
OCP Oral contraceptive pills
PAP Papanicolaou test

Funding

None.


Declaration of conflicting interests

None.


Disclosure Statement

The authors have nothing to disclose.


Consent for publication

Written informed consent was obtained.


Ethical approval

The study was approved by the Research & Ethics committee and the program director of Family Medicine before starting data collection. Approval of the Ministry of Education was obtained before contacting the selected schools.


Author details

Shatha Abdulaziz Alammar1, Nouf Saleh Al-salloum2, Tarek Elsaid3

  1. King Abdullah University Hospital, Riyadh, Saudi Arabia
  2. Alrajhi Private Banking, Riyadh, Saudi Arabia
  3. Prince Sultan Military Hospital, Riyadh, Saudi Arabia

References

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  3. Arbyn M, Castellsague X, de Sanjose S, Bruni L, Saraiya M, Bray F, et al. Worldwide burden of cervical cancer in 2008. Ann Oncol 2011; 22:2675–86; https://doi.org/10.1093/annonc/mdr015
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How to Cite this Article
Pubmed Style

Alammar SA, Al-salloum NS, Elsaid T. Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. IJMDC. 2018; 2(3): 97-102. doi:10.24911/IJMDC.51-1526304931


Web Style

Alammar SA, Al-salloum NS, Elsaid T. Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. http://www.ijmdc.com/?mno=299148 [Access: November 21, 2018]. doi:10.24911/IJMDC.51-1526304931


AMA (American Medical Association) Style

Alammar SA, Al-salloum NS, Elsaid T. Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. IJMDC. 2018; 2(3): 97-102. doi:10.24911/IJMDC.51-1526304931



Vancouver/ICMJE Style

Alammar SA, Al-salloum NS, Elsaid T. Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. IJMDC. (2018), [cited November 21, 2018]; 2(3): 97-102. doi:10.24911/IJMDC.51-1526304931



Harvard Style

Alammar, S. A., Al-salloum, . N. S. & Elsaid, . T. (2018) Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. IJMDC, 2 (3), 97-102. doi:10.24911/IJMDC.51-1526304931



Turabian Style

Alammar, Shatha Abdulaziz, Nouf Saleh Al-salloum, and Tarek Elsaid. 2018. Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. International Journal of Medicine in Developing Countries, 2 (3), 97-102. doi:10.24911/IJMDC.51-1526304931



Chicago Style

Alammar, Shatha Abdulaziz, Nouf Saleh Al-salloum, and Tarek Elsaid. "Awareness of cervical cancer and its prevention among high school female teachers in Riyadh." International Journal of Medicine in Developing Countries 2 (2018), 97-102. doi:10.24911/IJMDC.51-1526304931



MLA (The Modern Language Association) Style

Alammar, Shatha Abdulaziz, Nouf Saleh Al-salloum, and Tarek Elsaid. "Awareness of cervical cancer and its prevention among high school female teachers in Riyadh." International Journal of Medicine in Developing Countries 2.3 (2018), 97-102. Print. doi:10.24911/IJMDC.51-1526304931



APA (American Psychological Association) Style

Alammar, S. A., Al-salloum, . N. S. & Elsaid, . T. (2018) Awareness of cervical cancer and its prevention among high school female teachers in Riyadh. International Journal of Medicine in Developing Countries, 2 (3), 97-102. doi:10.24911/IJMDC.51-1526304931