Aldohaian et al.

BMC Women's Health (2019) 19:6

https://doi.org/10.1186/s12905-018-0701-2

RESEARCH ARTICLE Open Access

Using the health belief model to assess

beliefs and behaviors regarding cervical
cancer screening among Saudi women:
a cross-sectional observational study
Arwa I. Aldohaian* , Sulaiman A. Alshammari and Danyah M. Arafah

Abstract
Background: Cervical cancer in Saudi Arabia is ranked as the third most frequent gynecological cancer among
women. The Pap smear test is a screening test that can be used as a primary prevention tool for cervical cancer,
and prophylactic vaccination against HPV is also considered to be a factor in decreasing the prevalence of the
disease. This study aimed to assess women’s beliefs about cervical cancer and the Pap smear test. In addition, the
relationship between cervical cancer and the social and demographic characteristics was also evaluated.
Methods: A descriptive cross-sectional study was performed among Saudi women living in Riyadh in 2018. Women
were randomly selected, and the total sample size was 450. A predesigned self-administered questionnaire
that included the Health Belief Model scale was used to collect data. Data were analyzed using SPSS 21.0.
P values < 0.05 were considered as statistically significant in this study.
Results: Among the 450 participants, the Pap smear test uptake was 26% and the HPV vaccine uptake was
less than 1%. A low education level and family history for cervical cancer were significantly associated with
the belief of high susceptibility for developing cervical cancer (p < 0.05). The seriousness of the disease was
recognized by 38%, and the benefit of screening was recognized by 82% of the participants. In addition, 27%
of the participants perceived barriers to obtaining a Pap smear test.
Conclusions: This study showed a high level of perception regarding benefits and motivation, and a low
incidence of perceived barriers among women regarding cervical cancer screening. However, these attitudinal
aspects did not translate into practice, as reflected by the low uptake of the screening test. Our findings
imply that concerted efforts are needed to promote cervical cancer screening programs in Saudi Arabia. In
view of the planned implementation of Saudi vision 2030, which emphasizes on prevention, we recommend
launching a national cervical cancer screening program, to be available and accessible to all women in
primary health care centers and hospitals.
Keywords: Cervical cancer screening, Health belief model, HPV vaccine

* Correspondence: [email protected]
Department of Family & community medicine, College of Medicine, King
Saud Medical University, Riyadh, Kingdom of Saudi Arabia

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
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Aldohaian et al. BMC Women's Health (2019) 19:6 Page 2 of 12

Background zone, has helped to reduce the incidence and mortality

Cervical cancer is a preventable disease. It is the fourth rates of cervical cancer by 70% in developed countries
most common cancer among women globally. The esti- within 3 years after implementation of screening programs
mated number of cervical cancer cases in the world is [13–15]. It is well known that cancer develops 10 years or
528,000 per year. This cancer type is also considered to more after the development of detectable precancerous le-
be the second most common cancer in developing coun- sions. Women between 30 and 40 years of age are at a
tries with over 400,000 cases reported yearly. Cervical higher risk of precancerous lesions [16].
cancer is the third cause of cancer-related death in de- Accordingly, the Saudi guideline for cervical cancer
veloping countries (230,158 deaths per year) [1]. This screening recommends that the universal screening
means that 80% or more of the global burden of cervical strategy be followed [5]. The United States Preventive
cancer occurs in developing countries [2]. The explan- Services Task Force has recommended a Pap smear test
ation behind the higher mortality of cervical cancer in every 3 years for women aged between 21 and 65 years.
developing countries is that in these countries, the For women aged between 30 and 65 years who want to
spending on cancer prevention programs is only ap- increase the length of the screening interval, a Pap
proximately 5% of that spent by developed countries smear test combined with a HPV test conducted every 5
worldwide [3]. years is recommended [17].
In Saudi Arabia, cervical cancer is the third most com- Unfortunately, many women remain asymptomatic until
mon gynecological malignancy in Saudi women. The in- the disease has advanced, especially those women who are
cidence rate of new cases of cervical cancer was 1.9 per not sexually active. The presenting early symptoms of in-
100,000 in 2014 [4]. The estimated number of new cer- vasive cervical cancer are vaginal discharge, irregular
vical cancer cases and the number of deaths per year bleeding, postcoital spotting, and pre- or postmenopausal
was 152 and 55, respectively [5]. However, more than spotting or bleeding. Furthermore, more advanced symp-
40% of women having cervical cancer are diagnosed at toms are urinary frequency and urgency, lower abdominal
advanced stages in Saudi Arabia, compared to 25% in pain, severe back pain, and weight loss [18].
British Columbia, Canada. This high prevalence of delay It is essential to study the risk factors for cervical can-
in diagnosis is probably due to the lack of effective pre- cer among women as well as the emotional, cognitive,
vention and screening programs in Saudi Arabia [5, 6]. and environmental aspects, which influence the women’s
Studies have recognized a strong association between decision to participate in screening programs. The
cervical cancer and human papillomavirus (HPV) sero- Health Belief Model (HBM) focuses on a person’s
types 16 and 18 [7]. Almost 70% of cervical cases are health-related behavior for predicting future actions
caused by HPV 16 and 18 [8]. This virus affects changes [19]. The HBM has been tested, translated, and used to
in the cervical epithelium metaplasia, and such changes study women in different cultures [20].
usually occur more rapidly during puberty [7]. The Ad- According to this model, the decision to participate in
visory Committee on Immunization Practices in the programs designed to prevent or detect disease is deter-
United States of America (USA) has recommended rou- mined by many factors: perceived susceptibility to the
tine HPV vaccination for girls at the age of 11 or 12 health condition, awareness of the impact of disease on
years. Vaccination may be performed at any time until their health (perceived severity), perceived benefits of
the age of 26 years for those who have not been vacci- undergoing screening, and perceived barriers and costs
nated previously or have not finished the three-dose of the screening methods [19, 21].
series [9]. To date, there have been no studies employing the
There are many risk factors for cervical cancer, and in- HBM with regard to cervical cancer in Saudi Arabia.
clude the following: sexual activity at younger than 21 years Therefore, the aim of this study is to 1) assess women’s
of age (1.5-fold increase in risk compared to that for sexual beliefs toward cervical cancer and the Pap smear test in
activity initiated from 18 to 20 years of age and 2-fold in- Riyadh, and 2) to assess women’s knowledge and beliefs
crease for that initiated at less than 18 years of age), having regarding cervical cancer and the Pap smear test in rela-
multiple sexual partners, use of hormonal contraceptives tion to socio-demographic characteristics. The results of
for more than 5 years, increasing parity (three or more this study may provide a baseline assessment for future
full-term pregnancies), smoking, and a history of sexually intervention programs to promote early detection and
transmitted infections [10, 11]. The primary goal of cervical early management of cervical cancer.
cancer prevention is to reduce the incidence by addressing
the causes and the risk factors [12]. Methods
The cervical cancer screening test allows for early detec- Study design and setting
tion of cervical cancer. Pap smear screening, which identi- A cross-sectional study was conducted in all women
fies cytological abnormalities of the cervical transformation who attended the gynecology outpatient clinics in
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 3 of 12

Riyadh’s four main hospitals (King Khaled University, included the in the questionnaire and the topics covered
Alyamamah, King Saud Hospital, and the King Fahad in each part:
Medical City) and primary care centers in Riyadh that
were randomly selected by sectors as defined by the
ministry of sectoral health division. Two primary care Part I
centers from each sector (North, South, Center, East, Socio-demographic characteristics such as age, area of
and West) were selected (for a total of 10 primary care residence, educational status, working status, marital sta-
centers). tus, age at marriage, duration of marriage, number of liv-
ing children, usage of hormonal contraception, smoking,
Sample size and family history of cervical cancer.
We used the electronic sample size calculator, the open-
Epi software, to determine the required sample size. The Part 2
equation used for this calculation is given below: Knowledge about cervical cancer and about the Pap
smear test (yes, no, and I do not know options for being
n ¼ ½DEFF Npð1−pÞ=½ðd 2=Z 2 1−α=2 ðN−1Þ þ p ð1−pÞ familiar with the Pap smear test; the source of informa-
tion about the Pap smear test; knowledge about the Pap
smear test being the main cervical cancer screening test;
n = required sample size knowledge that cervical cancer is the most frequent can-
(N: Population size(for finite population correction cer among women; yes and no options for whether the
factor or fpc) (1000000)) participant had undergone a Pap smear test; knowledge
(p: Hypothesized % frequency of outcome factor in the about the appropriate age at which women require a Pap
population (50%+5)) smear test). Possible signs of cervical cancer were quer-
(d: Confidence limits as % of 100 (absolute + 5%)) ied in 10 items (weight loss, blood in the stool or urine,
Design effect (for cluster surveys-DEFF): 1 vaginal bleeding after the menopause or after having
z= confidence level at 95% (standard value of 1.96) sexual intercourse, pain during sexual intercourse, heavy
m = margins of error at 5% (standard value of 0.05) of prolonged menstrual periods, persistent vaginal bleed-
sample size = 385; the expected non-response rate was ing or discharge, pelvic pain and lower back pain) with
set at 20% “yes”, “no”, and “I do not know” options. Correct re-
Total sample size: 450 sponses for possible signs were assigned a score of one
point while the responses “No” or “I do not know” were
Sampling technique and study subjects assigned zero points.
The investigator collected the data from January 15, The possible risk factors of cervical cancer were quer-
2018 to February 30, 2018. Participants were selected ied using 8 items (HPV status, smoking, weakened im-
randomly as follows: 150 women from the King Khalid munity, use of contraceptive pills, history of Chlamydia
University Hospital, 150 from the Ministry of Health infections, marriage at a younger age, having many chil-
Hospitals (50 from each hospital), and 150 from primary dren, and not undergoing Pap smear tests regularly)
care centers (30 from each sector). using 5-point Likert-type scale options (strongly disagree
The inclusion criteria were: Saudi women (1), aged 18 (1 point) to strongly agree (5 points)). One item was re-
years or older (2) not diagnosed with gynecological can- moved from the original form from the risk factors sec-
cer, and (3) agreed to participate in the study. tion (having many sexual partners), since it is a sensitive
question in view of the conservative nature of the Saudi
Data collection society.
A predesigned self-administered questionnaire was com-
posed according to the findings from three validated
published studies that were conducted in Turkey, Egypt, Part 3
and Alahsa (Saudi Arabia). Furthermore, CHBM compo- Assessing the uptake of HPV vaccination with “yes,”
nents were added to the questionnaire after obtaining “no,” and “I do not know” options. The reasons for not
permission from the copyright owner [19, 22, 23]. This obtaining the vaccination and age of vaccination were
self-administered questionnaire includes questions about also queried. The internal consistency measure (Cron-
the following topics: (1) socio-demographic characteris- bach’s alpha) of the modified instrument was 0.784 for
tics; (2) knowledge about cervical cancer and about the knowledge of cervical cancer and the HPV vaccine (all
Pap smear test; (3) HPV)-related questions; and the (4) items), 0.86 for the signs and symptoms section (10
HBM scale for cervical cancer and for the Pap smear items), and 0.69 for the risk factors section (eight items),
test. The following section describes the various parts as revealed by pilot testing.
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 4 of 12

Part 4 well as to estimate the time needed to fill out the ques-
Using the HBM scale for cervical cancer and the Pap tionnaire. The questionnaires take approximately 15–20
smear test. The scale was used based on Victoria Cham- min to fill out. Modification of the questionnaire was
pion CHBM scale. The format, content, and validity of performed according to the results of the pilot study.
scale were tested and used in different language and cul- Women who participated in the pilot study were ex-
ture. Permission was obtained from Champion to adapt cluded from the main study.
the scale and to make the necessary changes to render
them in order to be valid for both Arabic language and
Data management
culture. This scale has five subscales: Perceived suscepti-
Data were analyzed using the SPSS 21.0 software (SPSS
bility to having disease was assessed by using three items
Inc., IBM, USA). The socio-demographic characteristics
“It is likely that I will get cervical cancer in the future”,
and knowledge of cervical cancer in participating women
“My chances of getting cervical cancer in the next few
are reported as mean, median, number, and percentage
years are high”, and “I feel I will get cervical cancer
distribution, as appropriate. The average score on the
sometime during my life.”; perceived seriousness of cer-
HBM Scale for cervical cancer and that for the Pap test
vical cancer was assessed by seven items, e.g., “ Problems
(reported as numbers, percentage, and median) were an-
I would experience with cervical cancer would last a
alyzed by parametric (independent sample t-test) and
long time.” Perceived benefits of undergoing a Pap
non-parametric tests (Kruskal Wallis test). Correlation
smear test were assessed by eight items, e.g., “Having
analysis (analysis of variance test) was used to determine
regular Pap smear Tests will help to detect changes to
the relationship between socio-demographic characteris-
the cervix before they turn into cancer.” Perceived mo-
tics, knowledge of cervical cancer, and the HBM scale
tivation toward improving health was assessed using
for cervical cancer and the Pap smear test. P values <
three items, e.g., “I eat well-balanced meals for my
0.05 were accepted as statistically significant.
health.” Perceived Pap smear test barriers were evaluated
using 18 items, e.g., “I am afraid to have a Pap smear
Test for fear of a bad result.” All items of the subscales Results
have the following five-point Likert-type response Four hundred and fifty women participated in the
choices: strongly disagree (1 point), disagree (2 points), present study. Table 1 shows that all participants in the
neutral (3 points), agree (4 points), and strongly agree (5 study lived in Riyadh city. The mean age of the study
points). Each of the subscales was assessed separately, participants was 32.9 ± 8.3 years. Majority of the partici-
and the total score was not calculated. Subscale scores pants (306; 68%) had a university level or higher educa-
were calculated for each participant. Higher scores indi- tion status. A little over half of the participants were not
cate stronger feelings about that construct. All subscales employed (244; 54%). The majority of participants were
had positive responses related to the screening behavior, married (366; 81%), while the rest were unmarried (84;
except for barriers which are negatively associated. In 19%). The mean age at marriage was 23.1 ± 4.4 years.
the original test, Cronbach’s alpha coefficients for the The mean duration of marriage was 10.3 ± 8.4 years.
five subscales were observed to fall between 0.62 and Roughly one-third of the participants (144; 32%) had
0.86. In this study, Cronbach’s alpha coefficients of 0.89 two or three children.
were observed for the five subscales. Table 2 shows that older women believed that it is
The English questionnaires were translated by two lan- beneficial to have a Pap smear test, while women who
guage experts into Arabic and were back-translated to had a low education level believed they were more sus-
English by two different independent language experts ceptible to developing cervical cancer. Women who were
according to Beaton-recommended guidelines [24]. This working had more knowledge about the signs of cervical
questionnaire was reviewed by two family physicians, cancer. Women who had a long marriage duration were
two gynecologists, and one community professor. All more motivated to promote self-health than did others.
the above reviewers are academic experts in their re- Women who had more children believed they were
spective fields. more susceptible to developing cervical cancer.
Non-smoking women perceived a benefit in undergoing
Pilot study a cervical cancer screening test. Additionally, women
Prior to the main study, the author conducted a pilot who were socially interactive with health professionals,
study with the questionnaire in 40 women to check the family, and friends were more aware about the Pap
applicability and clarity, and to identify any difficulties smear test barriers than were women who obtained their
with the questionnaire; the pilot study was also information from the media. Women who had a positive
employed to ensure the cultural and scientific appropri- family history of cervical cancer believed they were more
ateness of the instrument for the Saudi community, as susceptible to developing cervical cancer.
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 5 of 12

Table 1 Socio-demographic data of participants (n = 450) their vaccination status). The most popular reason for
Number Percent not receiving the vaccination was lack of knowledge
Age about the vaccine (91.1%), while less than one-tenth of
Mean ± SD 32.9 ± 8.3
the participants (6.4%) cited other reasons such as fear
of infection and refusal from parents or husband due to
Range (Min. – Max.) 18–57
high cost. Majority of the participants did not know the
Level of education appropriate age to receive the vaccination (258; 57.3%);
Primary + Read & write 10 2 the mean age for HPV vaccination among those who
Intermediate school 19 4 were vaccinated was 29.9 ± 8.6 years.
High school 115 26 Table 5 shows a comparison of HBM parameters with
University or higher 306 68
respect to different health institutions. We found no dif-
ference among participants with regard to HBM param-
Employment status
eters pertaining to cervical cancer except for the
Working 206 46 parameter “benefits” which showed statistically signifi-
Not working 244 54 cant differences among types of health institutions.
Marital status Table 6 shows that 12% of the participants considered
Married 366 81 themselves to be at risk of developing cervical cancer
Unmarrieda 84 19
(perceived susceptibility). Additionally, over 36% of the
participants agreed to the statements related to the ser-
Single 58 13
iousness of the disease. Regarding perceived benefits of
Divorced 22 5 the Pap smear test, approximately 82% of the partici-
Widow 4 1 pants believed that undergoing regular Pap smear tests
Age at marriage would help to find changes to the cervix before cancer
18 to 29 years 325 (82.9%) 83 develops, that regular Pap smear tests are the best way
Mean ± SD 23. 1 ± 4.4
to diagnose cervical cancer at an early stage, and that
cervical cancer treatment would be tolerable. In
Range (Min. – Max.) 12.0–38.0
addition, almost 70% of women were motivated to pro-
Marriage period mote their health (health motivation measures).
Mean ± SD 10.3 ± 8.4 Twenty-seven percent of the participants had experi-
Range (Min. – Max.) 0.08–37 enced barriers to obtaining a Pap smear test. For ex-
Number of children ample, 79% of participants preferred a female doctor
None 128 28
rather than a male doctor, 40.5% of participants would
feel embarrassed to lie on a gynecologic examination
One child 83 19
couch, 38% of women believed that they neglect or for-
2–3 children 144 32 get to undergo regular Pap smear tests. Additionally,
4–5 children 58 13 52% of the participants did not know where to go for a
6 or more children 37 8 Pap smear test, and 42% believed that “if there is cervical
SD standard deviation, Min minimum, Max maximum, a include (Single, cancer development in my destiny, having a Pap smear
Divorced, Widow) test cannot prevent it.” Furthermore, other perceived
barriers included a belief that the Pap smear test takes a
Table 3 shows that almost half of the participants long time to administer (11.7%), the cost of the test is
(48.7%) had knowledge about the Pap smear test. The high (21.6%), lack of time to schedule a test (15%), bad
most popular sources of relevant information were manners of health professionals (12.2%), and that the
health professionals (59.8%), followed by the media procedure may be painful (21%). With regard to pain,
(23.7%). More than two-thirds (74%) of the participants out of 101 of women who had undergone a Pap smear
had not undergone a Pap smear screening test. The test, only 29 (28.7%) women found it painful. In com-
mean age for undergoing a Pap smear screening test was parison, 54 (18%) out of 291 married women who did
31.8 ± 7.8 years. A majority of the participants (192; not undergo the test perceived that the Pap smear test
42.6%) selected the age range of 30–40 years, while 149 involves a painful procedure.
(33.1%) participants did not know the proper age for
undergoing Pap smear screening. Discussion
Table 4 shows that the majority of participants (424; This study focused on assessing health beliefs regarding
94.2%) did not receive the HPV vaccine, and that less cervical cancer and the Pap smear test among Saudi
than 1% had been vaccinated (the rest did not know women living in Riyadh, and evaluated the association
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 6 of 12

Table 2 Relationship between socio-demographic characteristics, knowledge, and HBM scale for cervical cancer and the pap test
Socio-demographic N Knowledge about Knowledge about Susceptibility Seriousness Benefits Health Motivation Barriers
characteristics sing of CC (n = 450) risk factors (n = 450) (n = 450) (n = 450) (n = 450) (n = 450) (n = 450)
Total Median Median Median Median Median Median Median
(Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.)
Age
≤ 20 years 16 2 (0–5) 19.5 (16–26) 7.5 (3–14) 20.5 (8–34) 34.5 (25–40) 11 (5–14) 54 (41–73)
21–30 years 198 3 (0–10) 21 (8–40) 7 (3–14) 21 (7–34) 35 (8–40) 12 (3–15) 51(18–74)
31–40 years 162 3 (0–10) 20 (8–40) 8 (3–15) 22 (7–35) 34 (8–40) 12 (3–15) 54 (18–85)
> 40 years 74 2.5 (0–10) 21 (8–31) 8 (3–15) 21.5 (8–35) 36 (26–40) 12 (6–15) 51.5 (28–72)
P-value 450 0.550 0.887 0.467 0.479 0.047 0.069 0.128
Education levels
Primary school 10 0.5 (0–7) 21 (16–35) 9 (7–14) 25 (15–33) 37.5 (28–40) 12 (6–15) 55.5 (34–72)
Intermediate 19 1 (0–6) 20 (14–24) 9 (3–13) 23 (8–34) 36 (22–40) 12 (3–15) 57 (33–72)
school
High school 115 2 (0–9) 20 (8–34) 7 (3–15) 22 (7–35) 35 (8–40) 12 (3–15) 51 (18–85)
University or 306 3 (0–10) 21 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 52 (18–80)
higher
P-value 450 0.029 0.075 0.010 0.126 0.359 0.483 0.125
Employment status
Working 206 3 (0–10) 21(8–40) 7.0 (3–15) 21 (7–35) 34.5 (9–40) 12 (3–15) 52 (20–81)
Not working 244 2 (0–9) 20 (8–40) 7.0 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 52 (18–85)
P-value 450 0.001 0.675 0.224 0.857 0.169 0.783 0.831
Marital status
Single 58 2.5 (0–9) 21 (14–40) 7 (6–15) 21.5 (8–35) 35 (8–40) 12 (3–15) 56 (35–90)
Married 366 3 (0–10) 20 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 56 (23–90)
Divorce 22 1 (0–9) 23 (8–27) 8.5 (3–15) 21 (7–27) 34.5 (8–40) 11 (3–15) 54.5 (37–73)
Widow 4 1 (0–4) 22.5 (15–30) 6 (9–15) 19 (16–21) 34.5 (10–40) 10.5 (5–15) 52.5 (44–54)
P-value 450 0.317 0.219 0.498 0 .568 0 .868 0 .326 0 .610
Age when married
Less than 18 years 33 4 (0–10) 20 (8–26) 8 (3–14) 20 (7–34) 36 (8–40) 12 (3–12) 58 (36–70)
18–29 years 325 3 (0–10) 21 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 56 (27–90)
30–40 years 34 1 (0–9) 23 (12–35) 7 (6–15) 22.5 (7–35) 33.5 (8–40) 12 (3–15) 58 (23–86)
P-value 392 0.708 0.056 0.057 0.422 0.052 0.977 0.792
Marriage period
1 month − 5 years 135 2 (0–10) 21 (8–40) 7 (3–15) 20 (7–35) 34 (17–40) 11 (5–15) 53 (21–85)
> 5–10 years 108 3 (0–10) 20 (11–40) 8 (3–14) 21 (7–35) 35 (8–40) 12 (3–15) 51 (18–77)
> 10 years 149 3 (0–10) 20 (8–33) 7.6 (3–15) 22.5 (7–35) 35 (19–40) 12 (5–15) 52 (20–81)
P-value 392 0.703 0.378 0.148 0.387 0.055 0.005 0.626
Number of children
None 128 2 (0–10) 21 (8–40) 7 (3–15) 22 (7–35) 34 (8–40) 12 (3–15) 55 (23–90)
One child 83 1 (0–10) 21 (12–40) 7 (3–15) 22 (7–35) 34 (8–40) 11 (3–13) 57 (37–88)
2 or 3 children 144 3 (0–10) 20 (8–40) 8 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 57 (28–90)
4 children or more 95 3 (0–10) 19.7 (8–33) 8 (3–15) 19.2 (9–35) 35.7 (8–40) 12 (3–15) 57 (27–72)
p-value 450 0.273 0.041 0.016 0.237 0.077 0.058 0.142
Use contraceptive
Yes 110 3 (0–10) 20 (8–40) 8 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 57 (27–78)
No 340 2 (0–10) 21 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 55 (23–90)
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 7 of 12

Table 2 Relationship between socio-demographic characteristics, knowledge, and HBM scale for cervical cancer and the pap test
(Continued)
Socio-demographic N Knowledge about Knowledge about Susceptibility Seriousness Benefits Health Motivation Barriers
characteristics sing of CC (n = 450) risk factors (n = 450) (n = 450) (n = 450) (n = 450) (n = 450) (n = 450)
Total Median Median Median Median Median Median Median
(Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.) (Min. – Max.)
P-value 450 0.383 0.573 0.629 0.912 0.425 0.156 0.481
Smoking
Yes 12 4 (0–6) 23.5 (17–28) 9 (8–15) 15.5 (12–31) 31.5 (9–40) 11.5 (3–15) 54 (46–88)
No 438 3 (0–10) 21 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 56 (23–90)
P-value 450 0.947 0.237 0.488 0.538 0.027 0.129 0.744
Whether she had information about the Pap test?
Yes 219 3 (0–10) 21 (8–40) 7 (3–15) 21 (7–34) 35 (8–40) 12 (3–15) 49 (18–81)
No 231 2 (0–10) 21 (8–40) 8 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 54 (18–85)
P-value 450 0.001 0.906 0.593 0.887 0.858 0.217 P < 0.0001
Source of the information about the Pap test is:
Health 121 3 (0–10) 21 (8–30) 7 (3–13) 21 (7–34) 35 (8–40) 11 (3–15) 48 (18–81)
professional
Family 17 5 (0–10) 18 (13–30) 7 (3–12) 20 (7–27) 35 (9–40) 12 (3–15) 42 (27–58)
Media 62 3 (0–9) 21 (13–40) 7 (3–13) 21 (10–32) 35 (24–40) 12 (5–15) 52 (37–65)
Other 19 4 (0–9) 22 (14–28) 8 (3–15) 22 (7–33) 36 (23–40) 12 (7–15) 51 (21–65)
P-value 219 0.096 0.061 0.897 0.658 0.900 0.265 0.005
Family history cervical cancer
Yes 22 2 (0–8) 22 (8–30) 9 (4–15) 23.5 (7–35) 35 (9–40) 11.5 (3–15) 54 (40–69)
No 400 3 (0–10) 21 (8–40) 7 (3–15) 21 (7–35) 35 (8–40) 12 (3–15) 52 (18–85)
I don’t know 28 2.5 (0–8) 20.5 (15–27) 7 (3–15) 21 (8–34) 33.5 (24–40) 12 (5–15) 51 (30–62)
P-value 450 0.945 0.626 0.014 0.263 0.760 0.196 0.736
HBM Health Belief Model, CC Cervical Cancer

between these beliefs and socio-demographic character- to note that, in our study, the media was less preferred
istics. Our results showed that 26% of participants had by women as a source of information, and more women
undergone a Pap smear test, which is in agreement with sought such information from health professionals.
data from other developing countries. The uptake of the Currently, some of Saudi Arabia’s major hospitals offer
Pap smear test was reported to be 23.8% in Kuwait [25], the HPV vaccine based on a doctor’s prescription. Thus,
21% in Jamaica [26], 21.9% in Turkey [27], 15.7% in primary healthcare physicians should provide more in-
Nepal [28], and 12% in Ghana [29]. In contrast, the Pap formation about the HPV vaccine and should recom-
smear test uptake rate has been reported to be much mend timely vaccination to their patients [33]. The
higher in developed countries, at 93% in the USA [30], present study showed a low uptake of HPV vaccine in
and 72% in the United Kingdom [31]. In fact, more than Saudi Arabia among women (1%); this uptake rate was
half of the participants in our study did not have any significantly lower than that reported from other coun-
knowledge about the cervical cancer screening test. This tries such as the United Kingdom (range: 44.0 to 93.4%)
lack of knowledge or incorrect information perceived by [34], USA (range: 56.1 to 60.4%) [35], Malaysia (77.0%)
the participants could be the main reason for the low [36], and Egypt (19.9%) [19]. This may be due to the lack
uptake rate of the Pap smear test, as has been shown in of a national HPV vaccination program in Saudi Arabia.
other studies [25, 28, 29, 32]. Hence, we recommend In a recent cohort study conducted in Saudi Arabia, it
that all possible efforts should be made to increase was reported that out of 400 screened cervical speci-
awareness of the importance of the Pap smear test, and mens, 67 specimens (17%) were positive for HPV DNA.
that the media should be recruited to help in this regard. There were 291 Saudi women, only 47 out of them
A similar study conducted in Turkey also recommends were positively tested for HPV. While there were 20
involving the media in programs dedicated to improving positive tests out of the 109 for the remaining
cervical cancer awareness [27]. However, it is interesting non-Saudi women (Philippines, Jordanian, European,
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 8 of 12

Table 3 Knowledge and practice of participants regarding the the test [38, 39]. However, Saudi women in this study
cervical screening test (n = 450) showed high scores for perceived benefits, motivation,
Number Percent and reported lower levels of perceived barriers to cer-
Do you know about the Pap test vical cancer screening, which is in contrast with the
Yes 219 48.7 findings of the previous systematic study. This apparent
discrepancy may be attributed to the low awareness of
No 231 51.3
the disease among the participating women, and because
If the answer to the previous question was “yes”, please answer the
following question (n = 219)
the screening test was offered only at tertiary care
The source of information for the Pap smear test hospitals.
Health professional 131 59.8 It is possible that a higher level of education and work-
ing status as seen in the present study were associated
Family 17 7.8
with better knowledge; these parameters were found to
Media 52 23.7
be statistically significant (P > 0.05) in our study. Along
Other (friends, neighbors, etc.,) 19 8.7 the same lines, a study conducted in the United Arab
The Pap smear test is the primary test used for cervical cancer screening Emirates found a positive association between a high
Yes 110 50.2 level of education or a “working” status and good know-
No 25 11.4 ledge about of cervical cancer [40].
However, women who had a low education level and a
I don’t know 84 38.4
positive family history of cervical cancer believed that
Cervical cancer is the most common cancer in women
they were more susceptible to developing cervical can-
Yes 63 28.8 cer; the latter finding is in agreement with that reported
No 66 30.1 by a Turkish study [27]. Another study found that
I don’t know 90 41.1 women who have a positive family history of cancer are
Did you undergo a Pap test?(excluded single women n = 392) more likely to undergo a Pap smear test [41].
Further, more than one-third of women perceived the
Yes 101 26
seriousness of the disease in the present study. Similarly,
No 291 74
one-third of participants in a Vietnamese-American
Appropriate age for screening for married women study also believed that cancer would threaten their rela-
I don’t know 149 33.1 tionship with their partner/husband and having cervical
15–20 41 9.2 cancer would change their whole life. However, these be-
21–29 51 11.4 liefs did not translate into the action of undergoing a
Pap smear test [42].
30–40 192 42.6
The present study showed that 27% of the participants
41–50 17 3.7
perceived several barriers to undergoing a Pap smear
Mean ± SD 31.8 ± 7.8 test. Socio-cultural barriers included feeling embarrassed
Range (Min. – Max.) 15.0–50 about having to undergo a gynecologic examination
SD standard deviation, Min minimum, Max maximum (40.5%) and not having access to a female doctor (79%).
Participants may feel embarrassed about showing their
South Asian, Americans and Africans). Another study private part/s to a physician during a physical examin-
also from Saudi Arabia found that 31% of participants ation, especially if the doctor is male. This finding is in
were positive for HPV DNA [37]. Further studies are line with a study conducted among Egyptian women
needed to measure the real prevalence of HPV at the (who shared similar Arabic and Islamic culture as Saudi
national level; thus, there is a need for implementing women) which showed that 76.9% of women prefer a fe-
HPV awareness campaigns and to promote HPV vac- male doctor to perform the Pap smear procedure [19].
cination programs in Saudi Arabia [37]. However, a study of Vietnamese-American women
In the present study, women perceived themselves to showed that women felt uncomfortable to undergo Pap
have a low susceptibility to cervical cancer and that this smear screening performed by a male doctor (38.8%)
cancer is a moderately serious disease. Hence, this belief [42]. Modesty and embarrassment were reported fre-
may have contributed to the low uptake of the screening quently as barriers for cervical cancer screening pro-
test. This finding is in concordance with a systemic re- grams among Arab Muslim women in the USA [43].
view of 12 studies, which reported that the Pap smear False interpretation of Islamic beliefs led to 42% of
test uptake was directly associated with higher scores of women to believe that “if cervical cancer development is
susceptibilities, seriousness, and benefits, and was indir- part of my destiny, having a Pap smear test cannot pre-
ectly associated with perceived barriers to undergoing vent it”; however, the Islamic faith encourages Muslims
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 9 of 12

Table 4 Human papilloma virus (HPV) vaccine uptake among study participants (n = 450)
Have you been vaccinated against HPV?
Yes 4 0.9%
No 424 94.2%
I don’t no 22 4.9%
If the answer to the previous question was “no,” then what was the reason for not being vaccinated?
I don’t know anything about the vaccine 410 91.1%
Other (expensive, fear of infection as a result of this vaccination, and refusal of parents or husband) 29 6.4%
No answer 7 1.6%
Age at vaccination for HPV
I don’t know 258 57.3%
18 years or less 13 2.9%
19–26 years 58 12.9%
27 years and more 121 26.9%
Mean ± SD 29.943 ± 8.588
Range (Min. – Max.) 10–50

to perform self-care, seek treatment, and to provide participants in our study considered the cost to be a bar-
health support [43]. It was narrated that the Prophet rier. This finding may be explained by the fact that the
(PBUH): said: “Seek treatment, O slaves of Allah! For majority of women in our study had free access to hospi-
Allah does not create any disease but he also creates tals or had medical insurance coverage, and that the in-
with it the cure, except for old age.” [44]. come of the Saudi population is relatively high [42, 45].
Healthcare organizations play an important role in The fear of pain involved in the Pap smear test pro-
popularizing and administering the Pap smear test. This cedure may prevent some women from undergoing the
is reflected in our study, since 52% of participants did test. Therefore, explaining the procedure may reduce
not know where to go for a Pap smear test; this finding anxiety and improve the uptake in women. Fortunately,
is in agreement with that reported by a similar study in our study, the percentage of Saudi women who had
conducted in Turkey. The investigators found that the experienced pain during the test (among those who had
Pap smear test uptake was four times lower if the undergone a Pap smear test) was low, at 28.7%; this fig-
women were not aware of where the test was offered ure is lower than that reported by a similar study con-
than if they were aware of this information. Therefore, ducted in Turkey (59%). The Turkish study found that
cervical cancer screening programs should provide infor- fear of pain among women made them four times less
mation not only regarding the benefits and the proced- likely to undergo a Pap smear test [45].
ure, but also provide adequate information of where it is There are several limitations to this study. The
offered [45]. women who participated in the study were selected
Many studies have shown that financial concerns may from Riyadh city, and were highly educated. There-
act as barriers to undergoing a Pap smear test if the fore, the results may not be generalizable to all Saudi
women have to pay for the test. More than half of the women. This cross-sectional study was conducted
women in two other similar studies believed it was too ex- using a self-administered questionnaire, and recall
pensive to have a Pap smear test; however, only 21% of bias cannot be ruled out due to such a study design.
Table 5 Comparative cervical cancer health belief model parameter data of participants as per health institutions (n = 450)
Health care centers KKUH MOH P-value
(n = 150) (n = 150) (n = 150)
Susceptibility (to cervical cancer) 8.0 (3.0) (3.0–13.0) 7.0 (3.0) (3.0–15) 7.5 (3.0) (3.0–15.0) 0.452
Seriousness (of cervical cancer) 21.0 (8.25) (7.0–33.0) 21.0 (8.25) (7.0–35.0) 21.0 (7.0) (7.0–35.0) 0.986
Benefits (of the Pap smear test) 34.0 (6.0) (8.0–40.0) 35.0 (6.0) (20.0–40.0) 36.0 (6.0) (8.0–40.0) 0.022
Health Motivation 12.0 (3.25) (3.0–15.0) 12.0 (4.0) (3.0–15.0) 12.0 (3.25) (3.0–15.0) 0.280
Barriers (to undergoing a Pap smear test) 52.5 (11.0) (18.0–81.0) 52.0 (12.0) (27.0–80.0) 51.0 (13.0) (18.0–85.0) 0.649
*Kruskal-Wallis test Median (Interquartile range) (minimum – maximum)
KKUH King Khaled University Hospitals, MOH Ministry of Health hospitals
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 10 of 12

Table 6 Health belief model scores of participants (single participants excluded: N = 392)
Variables Agree Neutral Disagree
Susceptibility
It is likely that I will get cervical cancer in the future 82 169 141
My chances of getting cervical cancer in the next few years are high 37 143 212
I feel I will get cervical cancer some time during my life 21 128 243
Average score 46.6 146.6 198.6
% 11.9 37.4 50.6
Seriousness
The thought of cervical cancer scares me 173 90 129
When I think about cervical cancer, my heart beats faster 137 99 156
I am afraid to think about cervical cancer 205 69 118
Problems I would experience with cervical cancer would last a long time 140 129 123
Cervical cancer would threaten a relationship with my husband 176 103 113
If I had cervical cancer my whole life would change 175 101 116
If I developed cervical cancer, I would not live longer than 5 years 50 143 199
Average score 150.8 104.8 136.2
% 38.4 26.7 34.7
Benefits
I want to discover health problems early 339 36 17
Maintaining good health is extremely important to me 344 31 17
I look for new information to improve my health 355 27 10
I feel it is important to carry out activities which will improve my health 352 31 9
Having regular Pap smear tests will help to find changes to the cervix, before they turn into cancer 325 54 13
If cervical cancer was found at a regular Pap smear test its treatment would not be so bad 283 63 46
I think that having a regular Pap smear test is the best way for cervical cancer to be diagnosed early 325 51 16
Having regular Pap smear tests will decrease my chances of dying from cervical cancer 276 77 39
Average score 325 46 20.8
% 82.8 11.7 5.3
Motivation
I eat well-balanced meals for my health 310 64 18
I exercise at least 3 times a week for my health 263 91 38
I have regular health check-ups even when I am not sick 240 93 59
Average score 271 82.6 38.3
% 69.1 21.1 9.7
Barriers
I am afraid to have a Pap smear test for fear of a bad result 88 98 206
I am afraid to have a Pap smear test because I don’t know what will happen 96 100 196
I don’t know where to go for a Pap smear test 203 73 116
I would be ashamed to lie on a gynecologic examination table 159 61 172
Undergoing a Pap smear test takes too much time 46 192 154
Undergoing a Pap smear test is too painful 83 188 121
Health professionals performing Pap smear tests are rude to women 48 166 178
I neglect or cannot remember to have a Pap smear test regularly 148 142 102
I have other problems in my life which are more important than having a Pap smear test 72 106 214
I am too old to have a Pap smear test regularly 33 87 272
Aldohaian et al. BMC Women's Health (2019) 19:6 Page 11 of 12

Table 6 Health belief model scores of participants (single participants excluded: N = 392) (Continued)
Variables Agree Neutral Disagree
There is no health center close to my house to have a Pap smear test 147 115 130
If there is cervical cancer development in my destiny, having a Pap smear test cannot prevent it 166 88 138
I prefer that a female doctor conducts a Pap smear test 310 58 24
I will never have a Pap smear test if I have to pay for it 85 91 216
I do not have time to get a Pap smear test 60 111 221
The Pap smear test may move the intrauterine device 35 234 123
My husband does not want me to get a Pap smear test 29 128 235
It Is difficult to get an appointment for a Pap smear test 125 123 144
Average score 107.4 120.1 164.5
% 27.4 30.6 41.9

Conclusions Ethics approval and consent to participate

This study showed a high incidence of perceived benefits The institutional review board of the College of Medicine, King Saud University,
approved the project proposal prior to the initiation of the study.
and motivation, and low incidence of perceived barriers
among women with regard to cervical cancer screening. Consent for publication
However, the data also showed that these perceived ben- Not applicable.

efits and motivation did not translate to practice, and Competing interests
only a small percentage of women underwent the The authors declare that they have no competing interests.
screening test. Furthermore, there is no current national
program for cervical cancer screening in Saudi Arabia. Publisher’s Note
Following the implementation of the new Saudi vision Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
2030 and health system reform, which emphasizes on
the importance of prevention, we recommend launching Received: 8 August 2018 Accepted: 12 December 2018
a national cervical cancer screening program, which is
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