|
Knowledge, attitudes
and practices regarding cervical cancer screening
among Female health care workers in primary
healthcare in Qatar
Dr. Amal
Alali (1)
Dr. Mohamed Salem (2)
Dr. Hisham Elmahdi (3)
Dr. Noora Alkubaisi (4)
Dr. Zeliakha Alwahedi (5)
Dr. Muna Taher (5)
Dr. Wafaa Yousuf (5)
Dr. Abeer Aljaber (5)
Dr. Ahmed Mostafa (3)
(1) Consultant
Family Medicine, Associate Director of Family
Medicine Residency program, Primary Health Care
Corporation -Qatar, Assistant Professor of family
medicine in clinical medicine, Weill Cornell
Medical College Qatar (WCMC-Q).
(2) Assistant Professor Family Medicine, Faculty
of Medicine - Suez Canal University - Egypt
(3) Specialist Family Medicine - Primary Health
Care Corporation - Qatar
(4) Consultant Community Medicine- Primary Health
Care Corporation - Qatar
(5) Consultant Family Medicine, Primary Health
Care Corporation - Qatar
Corresponding
author:
Dr. Amal
Alali
Consultant Family Medicine, Associate Director
of Family Medicine Residency program, Primary
Health Care Corporation -Qatar, Assistant Professor
of family medicine in clinical medicine, Weill
Cornell Medical College Qatar (WCMC-Q).
Email: aalali@phcc.gov.qa,
dr.alali2013@gmail.com
|
Abstract
Background:
Cervical cancer is the third most common
cancer among women worldwide. The female
health care workers who provide reproductive
health care are one of the most important
health knowledge providers and promoters.
Aim: The aim was to identify the
deficits in the Knowledge, attitudes,
and practice of female health care workers
in primary healthcare centers in order
to improve and raise their awareness of
cervical cancer screening to a level high
enough to provide accurate information,
good attitudes, and practice for cervical
cancer screening.
Objective(s):
(1) To assess the level of Knowledge,
attitudes and practices (KAP) regarding
cervical cancer screening among female
healthcare workers (HCWs) in primary health
care in Qatar.
(2) To examine factors influencing
female healthcare workers (HCWs) participation
in the cervical cancer screening program.
(3) To determine where the female
healthcare workers (HCWs) would prefer
to do the test and by whom.
Methods:
Descriptive cross sectional study was
conducted to assess knowledge, attitudes
and practices towards cervical cancer
screening in 90 female health care workers
working in Primary Health Care Centers
in the state of Qatar. Data collection
was done using a self-administered questionnaire
designed to assess knowledge, attitude
and practices toward cervical cancer screening
as well as factors influencing female
healthcare workers (HCWs) to participate
in the cervical cancer screening program
and where the female healthcare workers
(HCWs) would prefer to do the test and
by whom. Data were analyzed using Epi
Info. software. Data analysis was applied
to identify the statistical significant
limit of P < 0.05.
Results: The total sample included
90 female health care workers revealing
43.3 % were in the age group 30-39 years,
91.1% were non Qatari, 81.1% were nurses.
Among the participants 92.2 % had adequate
Knowledge regarding cervical cancer risk
factors (multiple partners, HPV, and family
history), while less than 9 % knew the
eligibility and screening interval for
cervical cancer screening. Of the female
participants, 57.8 % didn't feel they
were at risk, 84.4% believed that they
must be screened, 96.7 % were referred
for cancer screening, and 42.2% had a
pap smear before. There were significant
test results related to knowledge of (Smoking,
and Family History) as risk factors mainly
among residents which reaches 100% compared
to physicians and nurses. The study results
also showed that the most common factor
influencing participation in the cervical
cancer screening program are embarrassment
(17.3%), inadequate training (14.8%) and
exposed by colleagues (13.6%). Among the
participants, 94.5% preferred to have
a Pap smear test conducted by female physicians
either in the Well women clinic in the
primary health care centers (32.2%) or
Gynecological clinic in hospital (27.8%).
Conclusion: Most of the participants
group were nurses (81.1%). The present
study shows inadequate levels of knowledge
regarding the eligibility and screening
interval (9%). They had a good attitude
towards cervical cancer screening but
a low practicing percentage. In addition,
low percentage (32.2%) of them preferred
to have a pap smear in well woman clinics
in primary care and they preferred female
doctors to do cervical cancer screening.
Key words: knowledge, Attitude
and practice, cancer cervix, health care
providers, screening, primary health care.
|
Cervical cancer is the third most common cancer
among women worldwide, with an estimated 83,195
new cases and 35,673 deaths in 2012[1]. In the
developing countries, it is the leading cause
of gynecological cancer related morbidity and
mortality [2].
In Qatar 371,015 women are at risk for cervical
cancer (Female population aged >15
years). The current estimates indicate that
every year 15 women are diagnosed with cervical
cancer and 4 die from the disease. Cervical
cancer ranks as the 5th most frequent cancer
among women in Qatar and the 6th most frequent
cancer among women between 15 and 44 years of
age [3].
Cervical cancer has a long premalignant period
that provides the opportunity to screen and
treat before it becomes invasive cervical cancer
[4]. Along with this, it is largely preventable
by effective screening programs and considerable
reduction in cervical cancer incidence and deaths
has been achieved with systematic cytological
smear screening programs [5,6].
Primary prevention of cervical cancer aims
at reducing the incidence of cervical cancer
by controlling the causes as well as risk factors.
Human papilloma virus, a common sexually transmitted
infection, is the primary underlying cause of
cervical cancer. The risk factors for cervical
cancer are multiple sexual partners, early age
of onset of sexual activity, increasing parity,
use of hormonal contraceptives for 5 years or
longer,[7,8] current or previous sexually-transmitted
infection[9] and smoking[10].
Despite the active role of health care workers
to prevent cervical cancer, there are many obstacles
faced by health care workers to promote cervical
cancer screening. Lack of knowledge about the
risk factors, causes, symptoms [12, 13, 14],
ways of transmission [15, 16], screening intervals,
and HPV vaccine [15] are the main obstacles,
as well as poor attitude and practice for cervical
cancer screening [17, 18, 19].
An assessment of health care workers' knowledge
and practice of cervical cancer screening particularly
for female health care worker who provide reproductive
health care is considered important. Two studies
were conducted in the GCC to assess the knowledge,
attitude, and practice of primary care physicians
of cervical cancer screening. The studies found
that physicians have poor knowledge and practice
regarding cervical cancer screening and accordingly
a training program is recommended to improve
the physician's knowledge and practice [17,
18].
Another study confirmed the result of previous
studies conducted in Zimbabwe that revealed
that physicians and nurses had poor knowledge
regarding the predisposing factors of cervical
cancer, as well as negative beliefs about the
risk of developing cervical cancer and poor
screening behaviors [19]. Comparatively, one
study conducted in Ibadan found that the knowledge
about cervical cancer was higher among physicians
and inadequate among nurses [20]. On the other
hand, one study conducted in Tanzania to assess
the knowledge and practice of cervical cancer
screening among nurses found that nurses had
adequate knowledge regarding cervical cancer
causes, and ways of transmission but poor knowledge
regarding the risk factors, and symptoms of
cervical cancer [15].
Despite knowledge of the gravity of cervical
cancer and prevention among female medical workers
by screening using a Pap smear; the attitudes
and practices towards screening were negative
[21]. A Study in the UK showed that some medical
workers, including female physicians considered
themselves, not to be at risk of developing
cervical cancer. Moreover, they expressed feelings
of embarrassment and/or pain. The receipt of
an abnormal result and referral for colposcopy
causes high levels of distress [22].
Among barriers for effective cervical cancer
screening, lack of knowledge among medical workers
[15, 17, 18] inadequate training of staff [16],
not feeling at risk, lack of symptoms, carelessness,
fear of vaginal examinations, lack of interest
and test being unpleasant [12,13] is observed.
It is unlikely that those medical workers would
feel motivated to screen others or advise them
accordingly. Furthermore, anxiety regarding
physical privacy [23] and being busy [12] were
considered as barriers.
The female health care workers who deliver
reproductive health care are one of the most
important health knowledge providers and promoters
[11]. Therefore, if female physicians and nurses
have unsatisfactory knowledge, inappropriate
attitudes and practice toward cervical cancer
screening, they would not distribute the knowledge
to the community and cannot persuade =the patient
to perform a Pap smear [12]. Accordingly, improving
the knowledge and attitudes about cervical cancer
screening in such experts will encourage them
to readily provide accurate information and
motivate the general population to join screening
programs and motivate themselves to be screened
for cervical cancer.
In Qatar there is one study conducted to assess
knowledge, attitude and practice of women attending
the primary healthcare centers. The study showed
that knowledge and practice were inadequate
among those under 30 years old [24], but no
previous study has assessed the knowledge, attitude
and practices of cervical cancer screening among
female health care workers in the primary health
care setting.
Therefore, this study was conducted to assess
knowledge, attitude and practice of female health
care workers regarding cervical cancer screening.
The aim of this study is to raise the awareness
and importance of cervical cancer screening
among female HCWs and use the results of study
to be a guideline for improvement of knowledge,
practice and attitudes of primary healthcare
providers to a level high enough to provide
accurate information and good attitudes for
cervical cancer screening to the people and
patients. Also, early detection of cervical
cancer provides better outcomes.
Study design : Descriptive cross sectional
study to assess knowledge, attitude and practices
of cervical cancer screening among female health
care workers in primary health care centers
in Qatar.
Study area: This study was conducted
at Primary Health Care Corporation in Qatar,
where cervical cancer screening takes place
in primary health care centers by specialists
or consultants in family medicine through well
women clinics. These clinics are scheduled to
be one to two clinics in each health center
arranged in the morning or evening duty according
to each health center's situation; the capacity
of each clinic reaches an average of 25 patients
per clinic time.
Study subjects: It included all female
health workers who fulfilled the inclusion criteria:
Female health care workers working in health
centers (in the central region) inside Doha
city, including female physicians (consultants,
specialists, residents) and staff nurses. Exclusion
criteria included : Female health care workers
working in healthcare centers outside the central
region and Male staff in and out of Doha healthcare
centers.
Sample size and Sampling Technique: The
sample size was calculated according to expected
prevalence of good knowledge in a previous study
done in Saudi Arabia 2013 of 21.8% [25 ]. Assuming
a margin of error of 5%, and 95% confidence
level, the calculated sample size was 90; according
to Daniel equation [26] it includes all who
fulfilled the inclusion criteria. Selection
was based on systematic random sampling technique
of every 2nd patient until reaching the required
number. This was done in a 3 month period from
1st December 2015 to the end of February 2016.
Data collection: All the participants
were informed about the purpose of the study
and informed oral and written consent was obtained.
They were assured confidentiality of their personal
identifiable information. The interviews were
carried out between March 2016 and June 2016.
Participants answered a self-administered questionnaire
containing both coded and open-ended questions.
The first 8 questions gather demographic information
about the participants, the next 5 questions
assess the participants' awareness and knowledge.
In this study, awareness is defined as having
previously heard about cancer cervix screening.
Moreover, 3 questions were asked to assess participants'
attitudes; and 2 questions for the practices
regarding cervical cancer screening, one question
to understand the factors influencing female
HCWs participation in the screening program,
and 2 questions related to the location preference
to do the test and by whom.
We considered adequate knowledge if participants
mentioned at least 3 of the known risk factors
(early sexual intercourse, multiple sexual partners,
multi parity, low social economic status, Human
Papilloma Virus infection). The participants
knew that cervical cancer ranks as the 5th most
common cancer among woman in Qatar. The participants
knew that the human papillomavirus is the etiological
agent for cervical cancer, cervical cancer is
a curable disease and the participants should
correctly answer the screening eligibility and
interval of the cervical cancer screening that
should be performed.
Adequate Practice was assessed when the participants
answered that they referred their patients to
do Pap smear test and that they themselves are
examined if applicable. Attitude toward screening
was measured by answering yes to all of the
following questions: Do you think you are at
risk of getting cervical cancer? Do you think
that you should undergo screening for cervical
cancer? Do you think all eligible women for
cervical cancer screening should undergo it?
The questionnaire contents validity was confirmed
though an extensive literature review and experts
specialized in gynecology.
Ethical considerations : Participation
in the study was completely voluntary; the investigators
explained the purpose of the research and every
participant was able to withdraw at any time;
confidentiality was maintained. Approval by
Institutional Review Board from Research Section
- Primary Health Care Corporation in Qatar was
obtained before conducting the study PHCC/RC/14/07/2014
- Date: 30th April 2015.
Data Analysis : Data collected was entered
and analyzed by using Epi Info software and
statistical significant tests suitable for different
variables was used.
Sociodemographic
A
total
of
90
female
health
care
workers
were
interviewed,
43.3
%
were
in
age
group
30-39
years,
91.1%
were
non
Qatari,
81.1%
were
nurses,
83.3%
were
married,
97.8
%
were
nonsmokers,
and
86.5
%
had
no
chronic
medical
condition.
The
sociodemographic
details
of
the
respondents
are
shown
in
Table
1.
Knowledge
of
Cervical
Cancer
and
Risk
Factors
Most
of
the
female
HCPs
were
aware
of
cervical
cancer
screening
(97.8%).
Knowledge
on
risk
factors,
screening
eligibility
and
interval
is
shown
in
Table
2.
The
results
revealed
that
62.2%
had
fair
knowledge
about
ranking
cervical
cancer
in
Qatar,
92.2%
had
good
knowledge
regarding
(etiological
factors,
multiple
partners,
HPV,
and
family
history),73.3%
stated
curability
of
cervical
cancer.
Attitude
and
Practice
Towards
Cervical
Cancer
Screening
Table
3
shows
the
attitude
and
practice
towards
cervical
cancer
screening.
42.2%
of
the
female
HCWs
perceived
themselves
as
at
risk
of
developing
cervical
cancer,
84.4%
believed
that
they
must
be
screened,
96.7
%
were
referred
for
cancer
screening,
and
42.2%
had
a
pap
smear
before.
Table
4
shows
the
factor
influencing
participation
in
the
cervical
cancer
screening
program,
where
participants
prefer
to
do
the
screening
and
by
whom.
The
most
influential
factor
affecting
participation
in
cervical
cancer
screening
was
embarrassment
(17.3%)
inadequate
training
(14.8%),
does
not
want
to
be
exposed
to
colleagues
(13.6%)
and
not
feeling
at
risk
(12.3%).
Figure
(1).
Among
them
32.2
%
of
the
participants
prefer
to
do
pap
smear
in
primary
care
clinics
(Figure
2)
while
94.5%
preferred
to
have
a
pap
smear
by
female
physicians
(Figure
3).
Click
here
for
Figures
1,
2,
and
3
Table
5
shows
the
relation
between
knowledge
score
and
sociodemographic
factors
revealing
that
no
significant
test
results
were
found.
Table
6
shows
the
relation
between
individual
knowledge
items
and
participants'
job
revealing
that
there
is
significant
test
results
related
to
(Smoking,
and
Family
History)
mainly
among
the
residents
which
reaches
100%
compared
to
physician
and
nurses,
while
eligibility
criteria
and
screening
interval
was
significant
among
physicians
27%
compared
to
5%
among
nurses.
Table
7
shows
the
participants'
attitudes
towards
cervical
cancer
screening
and
job
description
revealing
no
significant
test
results
found.
Cancer
of
the
cervix
is
the
most
common
cancer
among
women
and
it
can
be
prevented
by
applying
the
appropriate
screening
test,
knowing
the
eligibility
and
screening
interval.
This
study
has
tried
to
capture
the
awareness
level,
knowledge
and
practice
toward
cervical
cancer
screening
among
female
HCWs.
In
this
study
a
total
of
90
female
health
care
workers
participated.
The
results
revealed
that
most
of
the
female
HCPs
were
aware
of
cervical
cancer
screening
(97.8%).
Among
them
43.3
%
were
in
the
age
group
30-39
years,
91.1%
were
non
Qatari,
81.1%
were
nurses.
This
study
found
that
female
health
care
workers
had
fair
to
good
knowledge
about
cervical
cancer
screening.
It
ranged
from
62.2%
to
97.8%
in
different
parameters
assessed.
It
is
matched
with
the
study
done
in
Saudi
Arabia
revealing
that
the
knowledge
about
cervical
cancer
screening
ranged
between
60.5%
to
90%
[25].
This
matching
could
be
explained
by
that
both
studies
were
done
among
female
health
care
workers
in
spite
that
the
Saudi
Arabia
study
included
only
physicians.
An
important
finding
is
that
of
most
of
the
participants,
mainly
the
nurses
(91.1%)
were
not
aware
of
the
eligibility
criteria
and
recommended
screening
interval
for
cervical
cancer
screening.
Comparatively
a
larger
percentage
of
Thai
nurses
correctly
identified
the
recommended
interval
and
the
eligibility
criteria
for
cervical
cancer
screening
found
by
Nganwai
et
al
[27].
This
could
be
attributed
to
the
training
they
have
attended.
With
regard
to
attitudes
toward
cervical
cancer
screening,
84.4%
think
that
they
must
be
screened,
revealing
positive
attitudes
towards
screening
,which
matched
with
the
study
done
in
Qatar
revealing
85.5%
showed
a
positive
attitude
towards
screening
for
cervical
cancer
[24],
however
that
study
was
done
among
females
from
the
general
population,
not
health
care
workers.
This
explains
increased
awareness
about
cervical
cancer
screening
among
females
in
Qatar.
In
regard
to
practices
towards
cervical
cancer
screening,
42.2%
had
pap
smear
before,
which
matched
with
the
same
study
done
in
Qatar
revealing
40%
did
have
a
Pap
smear
once
before
[24].
This
also
matched
as
female
health
care
workers
are
part
of
the
same
female
population
so
equal
percentages
were
expected.
In
Saudi
Arabia
one
study
showed
that
[25]
one
third
only
did
Pap
smears
in
the
physician
group
while
19
%
among
nurses.
This
difference
from
Qatar
could
be
explained
by
that
Saudi
Arabia
is
still
more
conservative
regarding
discussion
of
cervical
cancer
screening
and
considered
these
issues
as
confidential
matters,
especially
sexually
transmitted
diseases.
Among
the
eligible
participants
only
42.2%
had
a
pap
smear
before.
Our
finding
showed
that
the
most
common
factor
influencing
participation
in
the
cervical
cancer
screening
program
are
embarrassment
(17.3%),
inadequate
training
(14.8%),
they
don't
want
to
be
exposed
by
colleagues
(13.6%),
and
not
feeling
at
risk
(12.3%).
Comparatively
a
study
conducted
in
the
UK
showed
similar
findings
that
some
medical
workers,
including
female
physicians
considered
themselves,
not
to
be
at
risk
of
developing
cervical
cancer.
Additionally,
they
expressed
feelings
of
embarrassment
and/or
pain[23].
It
is
unlikely
that
these
staff
will
ever
motivate
others
or
advise
them
until
their
own
doubts
are
cleared.
Whatever
the
factor
influencing
participation
in
the
cervical
cancer
screening
program,
the
present
study
showed
that
94.5%
of
participants
preferred
to
have
the
Pap
smear
test
conducted
by
female
physicians
either
in
the
Well
women
clinic
in
the
primary
health
care
centers
(32.2%)
or
Gynecological
clinic
in
hospital
(27.8%).
Furthermore,
this
study
found
a
relation
between
individual
knowledge
items
and
participants'
job
revealing
that
there
is
significant
test
results
related
to
(Smoking,
and
Family
History)
mainly
in
the
residents
which
reaches
100%
compared
to
physicians
and
nurses,
while
eligibility
criteria
was
significant
among
physicians
27%
compared
to
5%
among
nurses.
Those
findings
make
us
think
more
of
nurse
education
and
training
on
the
topic
of
cervical
cancer
screening.
Studies
have
shown
it
is
possible
to
train
nurses
or
other
health
care
workers
to
screen
for
cervical
cancer,
and
they
play
an
important
role
in
successful
screening
against
cancer
of
the
cervix
[17,18].
There
is
an
urgent
need
to
integrate
cervical
cancer
prevention
topics
in
both
physicians'
and
the
nurses'
training
curriculum.
The
attitudes
and
beliefs
that
they
are
not
at
risk
or
they
don't
wont
to
be
exposed
and
feel
embarassed
to
do
the
screening
needs
to
change.
This
study
concludes
that
there
are
inadequate
levels
of
knowledge
regarding
the
eligibility
and
screening
interval
of
cervical
cancer,
particularly
among
nurses.
Female
HCWs
had
a
good
attitude
towards
cervical
cancer
screening
but
uptake
of
screening
for
cervical
cancer
is
minimal.
All
of
these
will
affect
their
decision
for
cervical
cancer
early
screening
and
referral.
The
findings
of
this
study
are
descriptive.
Qualitative
studies
should
be
done,
to
explain
the
understanding
level
of
HCWs
about
cervical
cancer
screening
importance
and
knowing
the
actual
reasons
for
very
low
uptake
of
cancer
screening,
despite
having
direct
access
to
screening
facilities
and
clinical
guidelines
for
cervical
cancer
screening
in
our
corporation.
The
finding
also
shows
that
the
female
health
care
workers,
mainly
nurses,
have
to
be
given
a
high
focus.
Our
corporation
needs
to
have
more
effectively
educated
and
informed
female
HCWs
about
cervical
cancer
and
screening.
Moreover,
it
needs
to
initiate
a
monitoring
system
e.g.
audit
to
make
sure
that
all
female
HCWs
should
be
motivated
to
apply
the
best
practice
regarding
cervical
cancer
screening
to
themselves
and
patients.
Also,
the
perceived
barriers
towards
screening
need
to
be
addressed.
The
strength
of
the
present
study
is
that
it
is
the
first
to
assess
knowledge,
attitude
and
practice
regarding
cervical
cancer
screening
among
female
healthcare
worker
where
incidence
of
cervical
cancer
is
high[3].
On
the
other
hand,
the
study
has
some
limitations.
Firstly,
this
study
is
based
on
a
self-reported
measure
that
especially
may
affect
reporting.
The
method
used
for
estimating
the
practice
of
Pap
smears
were
self-reported
history,
which
may
not
give
the
actual
picture
due
to
inaccurate
recall
bias
.
Secondly,
it
is
a
descriptive
cross
sectional
study
which
may
not
establish
temporal
relationships
between
exposure
and
outcome
measures.
Thirdly,
the
role
of
human
papilloma
virus
vaccine
was
not
addressed
well.
The
data
referred
in
the
current
report
have
been
gathered
with
budget
support
from
the
research
section
in
primary
health
care
corporation
(PHCC)
in
Qatar.
Authors
aknowledge
participation
in
data
collection
of
the
following
residents
affliated
to
Hamad
medical
Corporation
in
Qatar
(Dr:
Reem
Kamal,
Dr:
Noura
Alnachawi,
Dr:Ehab
Fadel,
Dr:Mustaafa
Mahmoud,
Dr:Nahed
Ragab,
Dr:Ahmed
Fayez,
and
Dr:Sara
Hamad).
1.
Bruni
L,
Barrionuevo-Rosas
L,
Serrano
B,
Brotons
M,
Cosano
R,
Muñoz
J,
Bosch
FX,
de
Sanjosé
S,
Castellsagué
X.
ICO
Information
Centre
on
HPV
and
Cancer
(HPV
Information
Centre).
Human
Papillomavirus
and
Related
Diseases
in
world.
Summary
Report
2014-04-08.
2.
Parkin
D,
Bray
F,
Devesa
S.
Cancer
burden
in
the
year
2000:
the
global
picture.
The
European
Journal
of
Cancer
2011;
37
(8):
4-66.
3.
Bruni
L,
Barrionuevo-Rosas
L,
Serrano
B,
Brotons
M,
Cosano
R,
Muñoz
J,
Bosch
FX,
de
Sanjosé
S,
Castellsagué
X.
ICO
Information
Centre
on
HPV
and
Cancer
(HPV
Information
Centre).
Human
Papilloma
virus
and
Related
Diseases
in
Qatar.
Summary
Report
2014-03-17.
4.
World
Health
Organization.
(2002).
Cervical
cancer
screening
in
developing
countries.
Report
of
a
WHO
consultation.
Geneva,
WHO
Press.
5.
Mahlck
G,
Jonsson
H,
Lenner
P.
Pap
smear
screening
and
changes
in
cervical
cancer
mortality
in
Sweden.
The
International
Journal
of
Gynecology
&
Obstetrics
1994;
44
(3):267-272.
6.
Elovainio
L,
Nieminen
P,
Miller
B.
Impact
of
cancer
screening
on
women's
health.
The
International
Journal
of
Gynecology
&
Obstetrics
1997;
58
(1):137-147.
7.
Chichareon
S,
Herrero
R,
Munoz
N,
Bosch
F,
Jacobs
M,
Deacon
J,
et
al.
Risk
factors
for
cervical
cancer
in
Thailand:
a
case
control
study.
Journal
of
the
National
Cancer
Institute
1998;
90
(1):50-7.
8.
Thomas
D,
Oin
O,
Ray
M,
Kuypers
J,
Kiviat
N,
Ashley
R.
Human
papillomavirus
and
cervical
cancer
in
Bangkok.
II.
Risk
factors
for
invasive
cervical
carcinomas
with
human
papillomavirus
type
16
and
18
DNA.
American
Journal
of
Epidemiololgy
2001;
153
(8):723-731.
9.
Koskela
P,
Anttila
T,
Bjorge
T,
Brunsvig
A,
Dillner
J,
Hakama
M,
et
al.
Chlamydia
trachomatis
infection
as
a
risk
factor
for
invasive
cervical
cancer.
International
Journal
of
Cancer
2000;85
(1):35?39.
10.
Louie
K,
Castellsague
X,
deSanjose
S,
Herrero
R,
Meijer
C,
Shah
K,
et
al.
Smoking
and
passive
smoking
in
cervical
cancer
risk:
Pooled
analysis
of
couples
from
the
IARC
multicentric
case?control
studies.
Cancer
Epidemiology
Biomarkers
and
Prevention
2011;20
(7):1379?90.
11.
Nilaweera
R
,
Perera
S,
Paranagama
N,
Anushyanthan
A.
Knowledge
and
Practices
on
Breast
and
Cervical
Cancer
Screening
Methods
among
Female
Health
Care
Workers:
A
Sri
Lankan
Experience.
Journal
of
Asian
Pacific
Journal
of
Cancer
Prevention
2012;
13
(4):1193-1196.
12.
Oranratanaphan
S,
Amatyakul
P,
Iramaneerat
K,
Srithipayawan
S.
Knowledge,
Attitudes
and
Practices
about
the
Pap
Smear
among
Medical
Workers
in
Naresuan
University
Hospital.
Asian
Pacific
Journal
of
Cancer
Prevention
2010;
11(6):
1727-1730.
13.
Mutyaba
T,
Mmiro
A,
Weiderpass
E.
Knowledge,
attitudes
and
practices
on
cervical
cancer
screening
among
the
medical
workers
of
Mulago
Hospital,
Uganda.
BMC
Medical
Education
2006;
6
(13):1-4.
14.
Aniebue
P,
Aniebue
U.
Awareness
and
practice
of
cervical
cancer
screening
among
female
undergraduate
students
in
a
Nigeria
university.
Journal
of
Cancer
Education
2010;
25(1):
106-108.
15.
Urasa
M,
Darj
E.
Knowledge
of
cervical
cancer
and
screening
practices
of
nurses
at
a
regional
hospital
in
Tanzania.
African
health
sciences
2011:
11
(1):
48-57
16.
Tran
N,
Choe
S,
Taylor
R,
Ko
W,
Pyo
H,
So
H.
Knowledge,
Attitude
and
Practice
(KAP)
Concerning
Cervical
Cancer
and
Screening
among
Rural
and
Urban
Women
in
Six
Provinces
of
the
Democratic
People's
Republic
of
Korea.
Asian
Pacific
Journal
of
Cancer
Prevention
2011;
12(11):
3029-3033.
17.
Badrinath
P,
Aswad
S,
Osman
N,
Deemas
E,
McIlvenny
S.
A
study
of
knowledge,
attitude,
and
practice
of
cervical
screening
among
female
primary
care
physicians
in
the
United
Arab
Emirates.
Health
Care
for
Women
International
2004;
25(7):663-670.
18.
Sait
K.
Knowledge,
attitudes,
and
practices
regarding
cervical
cancer
screening
among
physicians
in
the
Western
Region
of
Saudi
Arabia.
Saudi
Medical
Journal
2011;
32
(11):
1155-1160.
19.
Tarwireyi
F,
Chirenje
M,
&Rusakaniko
S.
Cancer
of
the
cervix:
knowledge,
beliefs
and
screening
behaviours
of
health
workers
in
Mudzi
District
in
Mashonaland
East
Province,
Zimbabwe.
Central
African
Journal
of
Medicine
2003;
49(7-8):83-86.
20.
Ayinde
O,
Omigbodun
A.
Knowledge,
attitude
and
practices
related
to
prevention
of
cancer
of
the
cervix
among
female
health
workers
in
Ibadan.
Journal
of
Obstetrics
and
Gynecology
2003;
23
(1):
59-62.
21.
Twaha
M,
Francis
M,
Elisabete
W..
Knowledge,
attitudes
and
practices
on
cervical
cancer
screening
among
the
medical
workers
of
Mulago
Hospital,
Uganda.
BMC
Medical
Education
2006;
6(13):
1-4.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1413529/pdf/1472-6920-6-13.pdf
(accessed
4
July
2012).
22.
Fylan
F.
Screening
for
cervical
cancer:
a
review
of
women's
attitudes,
knowledge
and
behavior.
British
Journal
of
General
Practice
1998;
48
(433):1509-1514.
23.
Terefe
Y,
Gaym
A.
Knowledge
attitude
and
practice
of
screening
for
carcinoma
of
the
cervix
among
reproductive
health
clients
at
three
teaching
hospital,
Addis
Ababa,
Ethiopia.
Ethiopian
journal
of
reproductive
health
2008;
2
(1)
:
14-24.
24.
Al-Meer
F.,
Aseel
M.,
Al-Khalaf
J,
Al-Kuwari
M,
Ismail
M.
Knowledge,
attitude
and
practices
regarding
cervical
cancer
and
screening
among
women
visiting
primary
health
care
in
Qatar.
The
Eastern
Mediterranean
Health
Journal
2011;
17
(11):
855-861
25.
Khalid
Sait.,
Knowledge,
Attitudes
and
Practices
regarding
Cervical
Cancer
Screening
in
Western
region
of
Saudi
Arabia.
Saudia
Med
J
2011;32(11):1155-1160.
26.
Daniel
WW
Biostatistics:
A
Foundation
for
Analysis
in
the
Health
Sciences
(7th
edtn)
John
Wiley
&
Sons,
New
York
(1999).
27.
Nganwai
P,
Truadpon
P,
Inpa
C,
Sangpetngam
B,
Mekjarasnapa
M,
Apirakarn
M,
et
al.
Knowledge,
attitudes
and
practices
vis-a-vis
cervical
cancer
among
registered
nurses
at
the
Faculty
of
Medicine,
Khon
Kaen
University,
Thailand.
Asian
Pac
J
Cancer
Prev
2008;9:15-8.
|
