Knowledge of cervical cancer screening among Omani women attending a university teaching hospital: a cross-sectional study

Cervical cancer is the fourth most common female cancer globally after breast, colorectal, and lung cancers, and is the second most common female cancer in Low- and Middle-Income Countries (LMICs) after breast cancer [1]. In 2020, it was estimated that approximately 604,127 women were diagnosed with cervical cancer worldwide, with an estimated 341,831 deaths attributable to the disease [2]. The majority (90%) of cervical cancer-related deaths in 2020 occurred in LMICs among women aged 15–49 years, largely due to a lack of access to screening programs, lack of availability of the Human Papillomavirus (HPV) vaccine, poor health infrastructure, and delays in diagnosis [2, 3].

Several risk factors are attributed to the development of cervical cancer, including HPV infection, low socioeconomic status, cigarette smoking, long-term use of oral contraceptives, marriage before the age of 18 years, early sexual intercourse, multiple sexual partners, and multiparity [4, 5]. Nonetheless, HPV infection (primarily genotypes 16 and 18) is considered to be the central etiological risk factor for cervical cancer [6]. According to data sourced from 900 invasive cervical cancer cases originating from 22 countries, 93% of biopsies have HPV DNA [4]. Thus, cervical cancer can be primarily prevented by HPV vaccination and routine Pap smear screening [4, 7].

While many countries have introduced national HPV vaccination programs over the last several decades, such programs remain rare in LMICs [7]. Furthermore, the implementation of Pap smear screening in LMICs is challenging due to poor attendance and lack of awareness of the importance of this type of screening in the prevention and early detection of cervical cancer [8]. Previous studies conducted in LMICs have indicated that women may encounter several barriers to cervical cancer screening, including poor knowledge regarding the importance of the HPV vaccine or Pap smear test, negative attitudes towards cervical cancer-related risk factors (particularly HPV infection), fear of the results, and concern regarding the gender of the doctor performing the screening test [9‐11]. In Oman, the HPV vaccine is not yet included in the Expanded National Immunization Program and is therefore not systematically provided by government-funded health institutes under the national Ministry of Health [12, 13].

In Oman, the incidence of cancer has increased over the past 20 years, a finding which may be attributed to population aging, rapid socioeconomic changes, and the increased prevalence of unhealthy lifestyle practices (e.g., tobacco use, physical inactivity, and unhealthy dietary habits), as well as advances in diagnostic and treatment modalities [14]. Among the population of 1.17 million women aged 15 years and older in Oman, there is a notable risk of developing cervical cancer; current estimates suggest that approximately 88 women are diagnosed with cervical cancer each year, resulting in 50 deaths [15]. Moreover, cervical cancer ranks as the fourth most common cancer among women of all ages in Oman and the third most common among women aged 15–44 years [14, 15].

Unfortunately, there are currently no available data on the prevalence of HPV in the general population of Oman. However, in Western Asia, the region to which Oman belongs, it is estimated that about 2.5% of women in the general population are affected by cervical HPV infection at any given time [16]. Furthermore, 72.4% of invasive cervical cancers in this region are attributed to HPV types 16 or 18 [16]. Additionally, a recent study from 2020 indicated that the prevalence of HPV infection remains high in Oman at 17.8% [17].

In Oman, the absence of a well-structured national screening program for cervical cancer and limited availability of Pap smear testing at the primary care level are significant concerns. This lack of accessibility and awareness regarding the availability of the Pap smear test are believed to be the main reasons for the high incidence of cervical cancer in the Middle East region [9, 18]. A previous study indicated that while most Omani women attending a tertiary teaching institute had heard of cervical cancer, they lacked specific knowledge regarding cervical cancer signs and symptoms, risk factors, and Pap smear testing [19]. Therefore, the present study aimed to assess knowledge, attitudes, and practices regarding cervical cancer and Pap smear screening among Omani women attending an outpatient clinic at a tertiary teaching hospital in Muscat, Oman. The study also aimed to establish correlations with various sociodemographic factors. These findings may be useful in informing future health promotion activities that aim to improve cervical cancer awareness in the general public and promote utilization of screening services in Oman.

Although cervical cancer is the one of the most common cancers among Omani women, there is as yet no established cervical cancer screening program in the country [12‐15]. Moreover, Pap smear testing is often only provided to married women and is unavailable at the primary healthcare level, performed solely in secondary and tertiary care facilities for diagnostic purposes. Combined with the lack of a national HPV vaccination program, such concerns are critical because the onus for cervical cancer screening and Pap smear testing therefore rests on the individual patient. As such, public knowledge and awareness of the importance of such screening and cervical cancer risk factors is crucial for early identification and prevention purposes. Thus, the present study was conducted in order to assess knowledge, attitudes, and practices regarding cervical cancer and Pap smear screening and to establish correlations with various sociodemographic factors among a cohort of Omani women attending an outpatient clinic at a tertiary teaching hospital in Muscat, Oman. The findings indicated that cervical cancer knowledge was limited, with 86% having heard of it, but only 59% believing in its preventability. Regarding Pap smear testing, 55% were aware, but 80% did not undergo such testing regularly. Sociodemographic factors such as marital status and previous awareness of cervical cancer were associated with higher knowledge scores and increased likelihood of participating in Pap smear practices.

In our study, although the vast majority of participants (86%) had previously heard of cervical cancer, only 55% had heard of Pap smear testing. A prior survey conducted in Oman similarly reported that 80% of participants had heard of cervical cancer [19]. This level of public awareness is high, possibly because such studies were conducted among patients, students, and employees at a tertiary care institute that routinely provides this service. According to Shrestha et al., only 18% of women who visited a tertiary care facility in Nepal knew of Pap smear testing, despite 66% having previously heard of cervical cancer [23]. In contrast, much higher rates of awareness (85 and 76%, respectively) were recorded among women accessing primary healthcare facilities in Qatar [24]. In Kuwait, 77% of married women visiting polyclinics had heard of Pap smear testing; similarly, 74% of Vietnamese American women surveyed in the USA had heard of the Pap smear test, although 90% were aware of cervical cancer [25, 26]. Differences in knowledge across different countries or regions may be due to cultural or healthcare system factors. For example, although Qatar is also a Middle Eastern country with a similar sociocultural milieu to Oman, the researchers noted that Pap smear testing is available at most primary health centers due to the country’s well-woman clinic program [24].

In the current study, various sociodemographic factors were found to have a significant impact on knowledge of cervical cancer and Pap smear testing, including marital status and a previous awareness of cervical cancer. Similar findings have been reported in studies conducted in Qatar, Kuwait, and the USA [24‐26]. In particular, married women were significantly more knowledgeable compared to their counterparts, as well as those who had previously heard of cervical cancer. Marital status likely influences cervical cancer-related knowledge in Oman due to family planning practices among married women, which would involve regular consultations with an obstetrician or gynecologist. These healthcare professionals often provide guidance on fertility, prenatal care, and childbirth preparation, possibly encompassing discussions about women’s general reproductive health, including cervical cancer. Indeed, this would tie in with the finding that knowledge scores were significantly associated with number of previous pregnancies. Studies from Kazakhstan have similarly shown that number of births is associated with increased awareness of HPV and cervical cancer screening practices [27, 28]. Indeed, the impact of marital status on cervical cancer-related knowledge may be more pronounced in conservative, religious countries like Oman where premarital sexual relations are strictly prohibited. Alternatively, as previously described, Pap smear testing is often offered only to married women in Oman; this might also explain why this group were more likely to demonstrate knowledge of cervical cancer and Pap smear testing. However, previous studies from Oman have also reported associations with other factors, such as education level, employment status, and income [19‐22]. These variations in findings could be due to differences in the research population and study design, as well as in the availability and accessibility of cervical cancer screening services in different healthcare settings and regions.

In terms of knowledge regarding cervical cancer, our study reported results in line with previous studies performed in Qatar and Kuwait [21, 22]. However, given that the majority of the participants (74%) had inadequate knowledge regarding cervical cancer and Pap smear testing, regardless of education level, this may indicate that the Omani public’s overall exposure to cervical cancer-related education is lacking. Unfortunately, only 24% of participants in the current study were aware of HPV infection as a risk factor for cervical cancer. This is concerning as previous research has identified a link between awareness of HPV as a major cause of cervical cancer and participation in Pap smear practices [27, 28]. Only 21% of the women in our study revealed that they had previously undergone Pap smear testing themselves. Despite this, the majority (75%) reported that they would be willing to undergo such testing in the future,

One of the limitations of this study includes the length of the questionnaire and the fact that the questionnaires were completed by participants while in the clinic’s waiting area, which can often be noisy and crowded. Moreover, some of the questions sought information on the participants’ past experiences and were related to potentially sensitive topics which could have resulted in recall or response bias. Secondly, the study was conducted in a single institution located in the capital city of Muscat; accordingly, the findings cannot be generalized to other institutions or regions of Oman, particularly more remote regions. Nonetheless, a strength of the study was that the participants involved in the study originated from all over the country as SQUH is one of the few tertiary-level institutions in Oman.

Overall, the present study identified inadequate awareness on matters related to cervical cancer, its risk factors, and screening methods among a sample of Omani women attending a tertiary outpatient clinic. Accordingly, more efforts need to be made to increase general awareness of cervical cancer and its screening methods and risk factors through various channels, including school-level interventions and health promotion activities. In particular, healthcare professionals should be encouraged to deliver cervical cancer-related information to female patients of appropriate age groups as they would be able to immediately and accurately respond to any inquiries and correct any misconceptions. Commonly reported barriers to taking part in cervical cancer screening in Oman include fear of being examined by a male doctor, being embarrassed, fear of the results, fear of pain, being healthy, being busy, and fear of the procedure itself [19‐22]. It is likely that these women would demonstrate more positive attitudes concerning Pap smear testing if they were to be reassured and given more detailed information concerning the test procedure itself. Much of this responsibility is likely to fall on the attending physician who should provide detailed information to female patients regarding cervical cancer screening, including its indications, ideal frequency, and possible complications. Moreover, healthcare professionals—whether at the primary, secondary, or tertiary care level—should seek to maintain appropriate channels of communication throughout the entire consultation and follow-up process in order to build up a trusting relationship with their patients, particularly given that such topics may be considered sensitive or embarrassing, especially in very conservative, religious societies.

The burden imposed by cervical cancer on health systems remains considerable, especially in LMICs such as Oman which lack adequate HPV vaccination and cervical cancer screening coverage. As such, public awareness of these issues is paramount to ensure early identification and prevention. Overall, the present study identified suboptimal awareness on matters related to cervical cancer, its risk factors, and screening methods among a cohort of Omani women attending a tertiary outpatient clinic. Despite this, most participants were generally accepting of the idea of undergoing Pap smear testing in future. Thus, it is strongly recommended that the Omani Ministry of Health consider implementing a national screening program in order to lower the incidence of cervical cancer. Moreover, awareness and education campaigns are also urgently needed to effectively inform the public on the importance of and indications for cervical cancer screening. Such campaigns might be implemented utilizing a multimedia approach; in addition, collaboration with other government sectors, such the Ministry of Education, would be helpful in order to reach adolescents and younger women and to incorporate knowledge about cervical cancer warning signs and risk factors into national school curricula. To support the execution of such initiatives, further research is recommended, particularly studies exploring ways to reduce barriers to Pap smear screening and the impact of religious and cultural factors on cervical cancer awareness and screening practices. In addition, comprehensive research is needed to determine the prevalence of HPV infection in the general population of Oman, with a focus on identifying specific genotypes. This could inform decisions related to the inclusion of the HPV vaccine in national immunization strategies.