Using the health belief model to assess beliefs and behaviors regarding cervical cancer screening among Saudi women: a cross-sectional observational study

Cervical cancer is a preventable disease. It is the fourth most common cancer among women globally. The estimated number of cervical cancer cases in the world is 528,000 per year. This cancer type is also considered to be the second most common cancer in developing countries with over 400,000 cases reported yearly. Cervical cancer is the third cause of cancer-related death in developing countries (230,158 deaths per year) [1]. This means that 80% or more of the global burden of cervical cancer occurs in developing countries [2]. The explanation behind the higher mortality of cervical cancer in developing countries is that in these countries, the spending on cancer prevention programs is only approximately 5% of that spent by developed countries worldwide [3].

In Saudi Arabia, cervical cancer is the third most common gynecological malignancy in Saudi women. The incidence rate of new cases of cervical cancer was 1.9 per 100,000 in 2014 [4]. The estimated number of new cervical cancer cases and the number of deaths per year was 152 and 55, respectively [5]. However, more than 40% of women having cervical cancer are diagnosed at advanced stages in Saudi Arabia, compared to 25% in British Columbia, Canada. This high prevalence of delay in diagnosis is probably due to the lack of effective prevention and screening programs in Saudi Arabia [5, 6].

Studies have recognized a strong association between cervical cancer and human papillomavirus (HPV) serotypes 16 and 18 [7]. Almost 70% of cervical cases are caused by HPV 16 and 18 [8]. This virus affects changes in the cervical epithelium metaplasia, and such changes usually occur more rapidly during puberty [7]. The Advisory Committee on Immunization Practices in the United States of America (USA) has recommended routine HPV vaccination for girls at the age of 11 or 12 years. Vaccination may be performed at any time until the age of 26 years for those who have not been vaccinated previously or have not finished the three-dose series [9].

There are many risk factors for cervical cancer, and include the following: sexual activity at younger than 21 years of age (1.5-fold increase in risk compared to that for sexual activity initiated from 18 to 20 years of age and 2-fold increase for that initiated at less than 18 years of age), having multiple sexual partners, use of hormonal contraceptives for more than 5 years, increasing parity (three or more full-term pregnancies), smoking, and a history of sexually transmitted infections [10, 11]. The primary goal of cervical cancer prevention is to reduce the incidence by addressing the causes and the risk factors [12].

The cervical cancer screening test allows for early detection of cervical cancer. Pap smear screening, which identifies cytological abnormalities of the cervical transformation zone, has helped to reduce the incidence and mortality rates of cervical cancer by 70% in developed countries within 3 years after implementation of screening programs [13–15]. It is well known that cancer develops 10 years or more after the development of detectable precancerous lesions. Women between 30 and 40 years of age are at a higher risk of precancerous lesions [16].

Accordingly, the Saudi guideline for cervical cancer screening recommends that the universal screening strategy be followed [5]. The United States Preventive Services Task Force has recommended a Pap smear test every 3 years for women aged between 21 and 65 years. For women aged between 30 and 65 years who want to increase the length of the screening interval, a Pap smear test combined with a HPV test conducted every 5 years is recommended [17].

Unfortunately, many women remain asymptomatic until the disease has advanced, especially those women who are not sexually active. The presenting early symptoms of invasive cervical cancer are vaginal discharge, irregular bleeding, postcoital spotting, and pre- or postmenopausal spotting or bleeding. Furthermore, more advanced symptoms are urinary frequency and urgency, lower abdominal pain, severe back pain, and weight loss [18].

It is essential to study the risk factors for cervical cancer among women as well as the emotional, cognitive, and environmental aspects, which influence the women’s decision to participate in screening programs. The Health Belief Model (HBM) focuses on a person’s health-related behavior for predicting future actions [19]. The HBM has been tested, translated, and used to study women in different cultures [20].

According to this model, the decision to participate in programs designed to prevent or detect disease is determined by many factors: perceived susceptibility to the health condition, awareness of the impact of disease on their health (perceived severity), perceived benefits of undergoing screening, and perceived barriers and costs of the screening methods [19, 21].

To date, there have been no studies employing the HBM with regard to cervical cancer in Saudi Arabia. Therefore, the aim of this study is to 1) assess women’s beliefs toward cervical cancer and the Pap smear test in Riyadh, and 2) to assess women’s knowledge and beliefs regarding cervical cancer and the Pap smear test in relation to socio-demographic characteristics. The results of this study may provide a baseline assessment for future intervention programs to promote early detection and early management of cervical cancer.

This study focused on assessing health beliefs regarding cervical cancer and the Pap smear test among Saudi women living in Riyadh, and evaluated the association between these beliefs and socio-demographic characteristics. Our results showed that 26% of participants had undergone a Pap smear test, which is in agreement with data from other developing countries. The uptake of the Pap smear test was reported to be 23.8% in Kuwait [25], 21% in Jamaica [26], 21.9% in Turkey [27], 15.7% in Nepal [28], and 12% in Ghana [29]. In contrast, the Pap smear test uptake rate has been reported to be much higher in developed countries, at 93% in the USA [30], and 72% in the United Kingdom [31]. In fact, more than half of the participants in our study did not have any knowledge about the cervical cancer screening test. This lack of knowledge or incorrect information perceived by the participants could be the main reason for the low uptake rate of the Pap smear test, as has been shown in other studies [25, 28, 29, 32]. Hence, we recommend that all possible efforts should be made to increase awareness of the importance of the Pap smear test, and that the media should be recruited to help in this regard. A similar study conducted in Turkey also recommends involving the media in programs dedicated to improving cervical cancer awareness [27]. However, it is interesting to note that, in our study, the media was less preferred by women as a source of information, and more women sought such information from health professionals.

Currently, some of Saudi Arabia’s major hospitals offer the HPV vaccine based on a doctor’s prescription. Thus, primary healthcare physicians should provide more information about the HPV vaccine and should recommend timely vaccination to their patients [33]. The present study showed a low uptake of HPV vaccine in Saudi Arabia among women (1%); this uptake rate was significantly lower than that reported from other countries such as the United Kingdom (range: 44.0 to 93.4%) [34], USA (range: 56.1 to 60.4%) [35], Malaysia (77.0%) [36], and Egypt (19.9%) [19]. This may be due to the lack of a national HPV vaccination program in Saudi Arabia. In a recent cohort study conducted in Saudi Arabia, it was reported that out of 400 screened cervical specimens, 67 specimens (17%) were positive for HPV DNA. There were 291 Saudi women, only 47 out of them were positively tested for HPV. While there were 20 positive tests out of the 109 for the remaining non-Saudi women (Philippines, Jordanian, European, South Asian, Americans and Africans). Another study also from Saudi Arabia found that 31% of participants were positive for HPV DNA [37]. Further studies are needed to measure the real prevalence of HPV at the national level; thus, there is a need for implementing HPV awareness campaigns and to promote HPV vaccination programs in Saudi Arabia [37].

In the present study, women perceived themselves to have a low susceptibility to cervical cancer and that this cancer is a moderately serious disease. Hence, this belief may have contributed to the low uptake of the screening test. This finding is in concordance with a systemic review of 12 studies, which reported that the Pap smear test uptake was directly associated with higher scores of susceptibilities, seriousness, and benefits, and was indirectly associated with perceived barriers to undergoing the test [38, 39]. However, Saudi women in this study showed high scores for perceived benefits, motivation, and reported lower levels of perceived barriers to cervical cancer screening, which is in contrast with the findings of the previous systematic study. This apparent discrepancy may be attributed to the low awareness of the disease among the participating women, and because the screening test was offered only at tertiary care hospitals.

It is possible that a higher level of education and working status as seen in the present study were associated with better knowledge; these parameters were found to be statistically significant (P > 0.05) in our study. Along the same lines, a study conducted in the United Arab Emirates found a positive association between a high level of education or a “working” status and good knowledge about of cervical cancer [40].

However, women who had a low education level and a positive family history of cervical cancer believed that they were more susceptible to developing cervical cancer; the latter finding is in agreement with that reported by a Turkish study [27]. Another study found that women who have a positive family history of cancer are more likely to undergo a Pap smear test [41].

Further, more than one-third of women perceived the seriousness of the disease in the present study. Similarly, one-third of participants in a Vietnamese-American study also believed that cancer would threaten their relationship with their partner/husband and having cervical cancer would change their whole life. However, these beliefs did not translate into the action of undergoing a Pap smear test [42].

The present study showed that 27% of the participants perceived several barriers to undergoing a Pap smear test. Socio-cultural barriers included feeling embarrassed about having to undergo a gynecologic examination (40.5%) and not having access to a female doctor (79%). Participants may feel embarrassed about showing their private part/s to a physician during a physical examination, especially if the doctor is male. This finding is in line with a study conducted among Egyptian women (who shared similar Arabic and Islamic culture as Saudi women) which showed that 76.9% of women prefer a female doctor to perform the Pap smear procedure [19]. However, a study of Vietnamese-American women showed that women felt uncomfortable to undergo Pap smear screening performed by a male doctor (38.8%) [42]. Modesty and embarrassment were reported frequently as barriers for cervical cancer screening programs among Arab Muslim women in the USA [43].

False interpretation of Islamic beliefs led to 42% of women to believe that “if cervical cancer development is part of my destiny, having a Pap smear test cannot prevent it”; however, the Islamic faith encourages Muslims to perform self-care, seek treatment, and to provide health support [43]. It was narrated that the Prophet (PBUH): said: “Seek treatment, O slaves of Allah! For Allah does not create any disease but he also creates with it the cure, except for old age.” [44].

Healthcare organizations play an important role in popularizing and administering the Pap smear test. This is reflected in our study, since 52% of participants did not know where to go for a Pap smear test; this finding is in agreement with that reported by a similar study conducted in Turkey. The investigators found that the Pap smear test uptake was four times lower if the women were not aware of where the test was offered than if they were aware of this information. Therefore, cervical cancer screening programs should provide information not only regarding the benefits and the procedure, but also provide adequate information of where it is offered [45].

Many studies have shown that financial concerns may act as barriers to undergoing a Pap smear test if the women have to pay for the test. More than half of the women in two other similar studies believed it was too expensive to have a Pap smear test; however, only 21% of participants in our study considered the cost to be a barrier. This finding may be explained by the fact that the majority of women in our study had free access to hospitals or had medical insurance coverage, and that the income of the Saudi population is relatively high [42, 45].

The fear of pain involved in the Pap smear test procedure may prevent some women from undergoing the test. Therefore, explaining the procedure may reduce anxiety and improve the uptake in women. Fortunately, in our study, the percentage of Saudi women who had experienced pain during the test (among those who had undergone a Pap smear test) was low, at 28.7%; this figure is lower than that reported by a similar study conducted in Turkey (59%). The Turkish study found that fear of pain among women made them four times less likely to undergo a Pap smear test [45].

There are several limitations to this study. The women who participated in the study were selected from Riyadh city, and were highly educated. Therefore, the results may not be generalizable to all Saudi women. This cross-sectional study was conducted using a self-administered questionnaire, and recall bias cannot be ruled out due to such a study design.

This study showed a high incidence of perceived benefits and motivation, and low incidence of perceived barriers among women with regard to cervical cancer screening. However, the data also showed that these perceived benefits and motivation did not translate to practice, and only a small percentage of women underwent the screening test. Furthermore, there is no current national program for cervical cancer screening in Saudi Arabia. Following the implementation of the new Saudi vision 2030 and health system reform, which emphasizes on the importance of prevention, we recommend launching a national cervical cancer screening program, which is available and accessible to all women at primary health care centers and hospitals. Such a program should be designed to improve awareness, to overcome any perceived barriers to screening, and hopefully to increase the uptake of screening. These measures may promote earlier detection of cancer among women and contribute to lowering the mortality rates associated with cervical cancer.