use of and attitudes and knowledge about pap smears among women in kuwait

Use of and Attitudes and Knowledgeabout Pap Smears among Women in Kuwait

Khadija El-Hammasi, M.B., Ch.B., Ola Samir, M.B., Ch.B., Soania Kettaneh, M.B., Ch.B.,Athari Al-Fadli, M.B., Ch.B., and Lukman Thalib, Ph.D.

Abstract

Objective: To estimate the lifetime prevalence of Pap smear among women in Kuwait and to assess theirknowledge about and attitude toward Pap smears.Methods: This was a descriptive cross-sectional study using a multistage cluster sampling method. We inter-viewed 299 women attending polyclinics in Kuwait using a self-administered questionnaire. Factors related tohistory of having a Pap smear, knowledge level, and willingness to participate in a screening program wereevaluated.Results: The lifetime prevalence of Pap smear was found to be 37% (95% CI 33-43). Forty-four percent of womenin our study had a Pap smear only once in their lives. History of having at least one Pap smear was significantlyrelated to such factors as age, total family income, marital status, history of cervical infection, and knowledge.The level of knowledge about cervical cancer varied among the participants. Forty-six percent of women wereuncertain about the symptoms of cervical cancer. About half the women recognized cervical infection, smoking,and having multiple sexual partners as risk factors for cervical cancer; however, only 10% recognized earlysexual intercourse as a risk factor. Willingness to participate in a future screening program varied significantlyaccording to educational level, employment status, and total family income.Conclusions: Although cervical cancer incidence and mortality are relatively low in Kuwait, they may beunderreported in the absence of a screening program. Moreover, lifetime prevalence of having a Pap smear wasfound to be considerably lower in Kuwait compared with developed countries.

Introduction

Cancer is a major health problem in the world today,where it is estimated that 50% of men and 33% of women

will experience some form of cancer during their lifetime.1

Cancer of the cervix uteri is the second most frequently oc-curring malignancy among women worldwide,2 with about410,000 new cases diagnosed annually.3 Cervical cancer inci-dence is reported to be higher in the developing countriesthan it is in the developed countries.4 Available data from theMiddle East show the prevalence of cervical cancer to behighly varied. For instance, the prevalence in Somalia wasestimated to be as high as 28.4%,5 whereas among Jordanianwomen, it was as low as 1.0%.6 There are few published dataon the incidence or prevalence of cervical cancer in Kuwait;however, a report by the cancer registry in Kuwait estimatedthe annual incidence of cervical cancer to be 6.8=100,000.7 Arecent study also showed that there is an increase in the rate of

cytological abnormalities in the cervix among young womenin Kuwait.8

Pap smear, the most popular screening tool, was first in-troduced by Papanicolaou in 1928. It is a simple test that takesonly a few minutes yet is efficient in detecting early changes incervical cells. The sensitivity of the Pap smear has been re-ported to range from 40% to 70%, and the generally acceptedfalse negative rate is about 15%–25%. This false negative ratedoes not compromise the screening strategies as long assmears are performed frequently enough.9 Evidence-basedrecommendations and guidelines about the age range ofwomen and time intervals for screening programs have beenwell developed. The National Health Service CervicalScreening Program (NHSCSP) in the U.K. recommends wo-men aged 25–35 years should be recruited into the screeningprogram every 3 years.10 Almost all the developed countriesas well as a number of developing nations have introducedwell-structured screening programs using the Pap smear, but

Department of Community Medicine and Behavioral Sciences, Faculty of Medicine, Kuwait University, Kuwait.

JOURNAL OF WOMEN’S HEALTHVolume 18, Number 11, 2009ª Mary Ann Liebert, Inc.DOI: 10.1009=jwh.2008.1227

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no such screening programs exist in Kuwait or in other Mid-dle East or Arab countries.

Although Kuwaiti hospitals have had the facilities to carryout Pap smear testing since its introduction to Kuwait in the1980s, no proper screening program has been developed.11 Inthis study, we attempt to quantify the approximate lifetimeprevalence of Pap smears among women in Kuwait. We alsoevaluated the experience, attitude, and knowledge related tothe Pap smear in our population. We envisage that our find-ings should stimulate public health professionals to considerdeveloping a cervical cancer screening program in this region.Our hypotheses were that (1) women in Kuwait have a lowprevalence of ever having a Pap smear compared with nationswith proper cervical screening program and (2) women inKuwait are not well informed about cervical cancer and Papsmear screening.

Materials and Methods

This is a descriptive cross-sectional study including 299women attending polyclinics in Kuwait. Both Kuwaiti andnon-Kuwaiti women attending the polyclinics for any reasonduring the data collection period were included in this study.A multistage cluster sampling method was used to randomlychoose the polyclinics in different governorates. Four of sixgovernorates, namely, Ahmadi, Capital, Farwaniya, andHawali, were selected as the first step in the multistage sam-pling process. Then, four polyclinics were randomly selectedfrom each of these selected governorates using a samplingframe that was obtained from the Ministry of Health. Thus, atotal of 16 polyclinics were surveyed in this study. We visitedeach of the selected polyclinics and invited all women toparticipate in the study, and all invited polyclinics agreed toparticipate. We obtained written informed consent from allparticipants. Data were collected using a self-administeredquestionnaire, approaching a minimum of 17 women in eachgovernorate. The average response rate was 91.8%. The mainreason for refusing to take part in the survey was being illit-erate.

Research instrument

A self-administered questionnaire was especially designedfor the study by the authors. It consists of 20 questionsgrouped into five sections, sociodemographic characteristics;marriage-related factors; history of cancer and cervical infec-tion; knowledge about cervical cancer; and knowledge, ex-perience, and attitudes toward the Pap smear, whether theyever had one, and reasons for having it. Both the question-naire and the consent were provided in Arabic and English.

A pilot study was conducted with 9 women in Al-Shaa’bpolyclinic in order to assess the suitability of the questionnaireand the logistics of the study in general. Completion of thequestionnaire tools 5–10 minutes. The women were interestedin the topic and commented that the questions were clear andprecise; thus; no major modifications were required.

Data analysis

Data entry and analysis were performed using StatisticalPackage for Social Scientists, version 13.0 (SPSS, Inc., Chicago,IL). It began with a descriptive analysis and computing theknowledge score. Because we could not find a standardized

knowledge score for cervical cancer and Pap smear, we tookthe participants’ answers to questions about cervical cancersymptoms and risk factors and about the reasons for having aPap smear to compute a knowledge score. Correct answers toeach of the knowledge questions were assigned a þ1 score,wrong answers were assigned a �1 score, and ‘‘don’t know’’answers were assigned 0. The participants’ scores were be-tween �7 and þ10, with approximately normal distribution.We divided the scores into low, moderate, and high into ter-tiles; those who scored 0 or less were classified as lowknowledge, those who scored between þ1 and þ3 wereclassified as moderate knowledge, and the rest were classifiedas high knowledge. Associations between knowledge scoresand age, governorate, marital status, age at first marriage,number of marriages, nationality, education, employment,combined family income, history of cancer, and history of Papsmear were carried out using appropriate statistical methods.These include chi-square and chi-square for trend tests.

Results

Our results showed that about 37% (95% CI 32-43) of therespondents ever had a Pap smear. Of those, about 32% had itwithin the past year, and about 41% had it between 1 and 3years prior to our study. We also investigated the reasons forhaving a Pap smear. About 19% indicated they had it forscreening, and about 18% did because of their physicians’concern. Only a few (<1%) had a Pap smear because of afamily history of cervical cancer.

Older women tended to have a higher rate of ever having aPap smear compared with younger women, particularly those<30 years of age ( p< 0.001). The chance of having a Papsmear also linearly increased with increased family income( p< 0.002). However, having a Pap smear was not found to beassociated with such factors as educational level, employmentstatus, nationality, or residential governorates where womenlived (Table 1).

As expected, unmarried women had a significantly lowerincidence of having a Pap smear (about 2%) than those mar-ried (42%) and those divorced or widowed (46%). There wasalso a highly significant association between having a Papsmear and a history of cervical infection ( p< 0.001). About74% of women who had a previous cervical infection had aPap smear. However, there was no significant associationbetween having a Pap smear and history of any cancer in thewomen or their families. Age at marriage and number ofmarriages were also not statistically related to having a Papsmear (Table 2).

In general, women’s knowledge of the symptoms and riskfactors of cervical cancer was poor in our population, and about46% were unaware of the symptoms of cervical cancer. Fur-thermore, about 65% of the women did not recognize that ir-regular bleeding could be a symptom of cervical cancer.Although early sexual intercourse is one of the most importantrisk factors for cervical cancer, only about 10% of the womenknew that. Cervical infection, smoking, and having multiplesexual partners are important risk factors for cervical cancer,and they were recognized correctly by 50% of the women.However, there was a lack of awareness related to othersymptoms, such as bleeding, pain, and mucoid secretions.

Interestingly, 44% of the participants thought the reason fordoing a Pap smear was to detect cervical infection. Only about

1826 EL-HAMMASI ET AL.

25% of the participants thought that it was done to detectcancerous cells in the cervix.

In terms of women’s source of information, about 42% ofthe women were told about a Pap smear by their physicians,and about 22% had never heard about it. Three quarters of theparticipants prefer a female doctor to take the smear, and 15%indicated no gender preference. We found that whether theyhad a Pap smear or not, most women were willing to partic-ipate in a screening program if one becomes available. About84% of those who have had a Pap smear were willing toparticipate in any future screening programs, and 44% per-ceived no barriers to participation. Of those who were hesitantto participate in a screening program, embarrassment (22%)and fear of the diagnosis of cancer (14%) were the mostcommon perceived barriers. A very few (<2%) thought that ascreening program would have no value.

Except for educational level and history of having a Papsmear, the association between knowledge score and othervariables, namely, age, governorate, nationality, marital sta-tus, age at first marriage, number of marriages, employmentstatus, combined family income, and history of any cancer,was not significant. The higher the educational attainment,the more likely the women would be aware of the symptomsand risk factors for cervical cancer ( p< 0.01). Those who had aPap smear were more aware of cervical cancer ( p¼ 0.004)than those who had not (Table 3).

Willingness to participate in a screening program wassignificantly associated with educational level, employment,and total combined family income but only marginally asso-ciated with knowledge score. There was an increasing trend ofwillingness to participate as the educational level increased( p¼ 0.014). Our results suggested that currently employedwomen wanted to participate more in such a program thandid unemployed or retired women ( p¼ 0.033). Our resultsalso showed no particular trend with regard to the associationbetween total combined family income and willingness toparticipate. In general, women whose knowledge score washigh were more willing to participate than those with a low ormoderate knowledge score, although, the differences wereonly marginally significant ( p¼ 0.067). Age, residential gov-ernorate, nationality, marital status, age at first marriage, andnumber of marriages were not be found to be associated with

Table 1. Sociodemographic Characteristics

of Women Attending Polyclinics in Kuwait (n¼ 299)

Variable Total n(%)

Age (years)a

15–19 24(7.9)20–29 92(30.5)30–39 109(36.1)40–49 58(19.2)�50 19(6.3)

NationalityKuwaiti 218(72.2)Non-Kuwaiti, Arab 67(22.2)Non-Kuwaiti, Non-Arab 17(5.6)

GovernorateCapital 80(26.3)Hawali 80(26.3)Ahmadi 73(24.0)Farwaniya 71(23.4)

Educational levela

No formal education=primary school 17(5.7)Intermediate school 40(13.5)High school 90(30.3)Diploma 72(24.2)University degree or higher 78(26.3)

Employment statusEmployed 132(44.9)Unemployed=student 116(39.5)Retired 46(15.6)

Combined family income (KD=month)a

<500 79(26.5)500–999 134(45.0)1000–1499 55(18.5)�1500 30(10.0)

Marital statusNever been married 43(14.2)Married 233(77.2)Divorced=widowed 26(8.6)

Age at first marriage (years)a

<20 97(44.9)20–24 84(38.9)25–29 26(12.0)�30 9(4.2)

Number of marriages1 216(85.7)�2 36(14.3)

aAssociations were assessed using the chi-square for trend test.Other associations were assessed using the chi-square test.

Table 2. Association between Having a Pap Smear

and Sociodemographic Characteristics, Marital

Status, and History of Cervical Infection

or Cancer in Women Attending Polyclinics

in Kuwait (n¼ 299)

VariableTotaln(%)

Had Papsmear n(%) p value

Age (years)a

15–19 24(7.9) 2(8.3) <0.00120–29 92(30.5) 25(27.5)30–39 109(36.1) 44(41.5)40–49 58(19.2) 31(54.4)�50 19(6.3) 8(42.1)

Employment statusEmployed 132(44.9) 50(37.9) 0.099Unemployed=student 116(39.5) 37(31.9)Retired 46(15.6) 23(50.0)

Combined family income (KD=month)a

<500 79(26.5) 22(28.9) 0.002500–999 134(45.0) 44(33.3)1000–14999 55(18.5) 26(47.3)�1500 30(10.0) 17(56.7)

Marital statusNever been married 43(14.2) 1(2.4) <0.001Married 233(77.2) 97(42.2)Divorced=widowed 26(8.6) 12(46.2)

History of cervical infectionYes 62(22.6) 46(74.2) <0.001No 212(77.4) 57(27.3)

History of cancerb

Yes 68(22.9) 27(39.7) 0.579No 229(77.1) 81(36.0)

aAssociations were assessed using the chi-square for trend test.Other associations were assessed using the chi-square test.

bWe asked about cervical cancer and breast cancer.

PAP SMEAR AMONG WOMEN IN KUWAIT 1827

willingness to participate in a screening program (Tables 4and 5).

Discussion

In view of the absence of cervical cancer screening pro-grams in Kuwait, there are only scant data available to com-pare the overall prevalence. Our estimate of the prevalence ofever having Pap smear is not much different from those re-ported from other Arab and Middle Eastern countries incomparable populations.12,13 Like Kuwait, most if not all ofthese countries lack cervical cancer screening programs.

Hence, it is not surprising that our region has a lower prev-alence of Pap smear compared with countries with well-developed cervical cancer screening programs (Fig. 1).

Our results showed that the prevalence of having a Pap smearwas higher among women aged �30 but notably lower amongthose aged �50. This finding is similar to that of Hewitt et al.,14

who observed that U.S. women >65 years of age were un-derscreened for cervical cancer. This group of women receivesless care from obstetricians and gynecologists, which may par-tially explain the reduced prevalence of the Pap smear.18

We also evaluated the association between educationallevel and the likelihood of having a Pap smear but found no

Table 3. Level of Knowledge about Cervical Cancer and Various Selected Sociodemographic Factors,

Marital Status, and History of Cancer among Participants (n¼ 299)

Variable Low n(%) Medium n(%) High n(%) p value

Age (years)15–19 7(29.2) 8(33.3) 9(37.5) 0.28520–29 33(35.9) 29(31.5) 30(32.6)30–39 30(33.0) 44(40.4) 29(26.6)40–49 21(36.2) 18(31.0) 19(32.8)�50 7(36.8) 10(52.6) 2(10.6)

GovernorateCapital 29(36.3) 30(37.5) 21(26.2) 0.813Ahmadi 22(30.2) 32(43.8) 19(26.0)Farwanya 20(28.2) 26(36.6) 25(35.2)Hawali 34(42.5) 22(27.5) 24(30.0)

Marital statusNever been married 15(34.8) 14(32.6) 14(32.6) 0.832Married 81(34.8) 84(36.0) 68(29.2)Divorced=widowed 8(30.8) 11(42.3) 7(26.9)

Age at first marriage<20 34(35.1) 36(37.1) 27(27.8) 0.46020–24 26(30.2) 34(39.6) 26(30.2)�25 12(34.3) 10(28.6) 13(37.1)

NationalityKuwaiti 73(33.5) 84(38.5) 61(28.0) 0.431Non-Kuwaiti, Arab 27(40.3) 22(32.8) 18(26.9)Non-Kuwaiti, non-Arab 5(29.4) 2(11.8) 10(58.8)

EducationNo formal education=primary school 9(52.9) 6(35.3) 2(11.8) 0.028Intermediate school 16(40.0) 17(42.5) 7(17.5)High school 30(32.6) 33(35.9) 29(31.5)Diploma 26(35.6) 25(34.2) 22(30.2)University degree or higher 24(30.0) 28(35.0) 28(35.0)

Employment statusCurrently employed 40(29.6) 51(37.8) 44(32.6) 0.372Unemployed=student 47(39.8) 40(33.9) 31(26.3)Retired 15(32.6) 17(37.0) 14(30.4)

Combined family income (KD=month)<500 33(41.8) 26(32.9) 20(25.3) 0.403500–999 39(29.1) 48(35.8) 47(35.1)1000–1499 24(43.6) 19(34.6) 12(21.8)�1500 6(20.0) 14(46.7) 10(33.3)

Number of marriages1 71(32.6) 83(38.1) 64(29.3) 0.832�2 15(39.5) 12(31.6) 11(28.9)

History of cancerYes 16(23.5) 30(44.1) 22(32.4) 0.118No 84(36.7) 80(34.9) 65(28.4)

Cervical smear doneYes 27(24.4) 43(38.7) 41(36.9) 0.004No 75(39.9) 66(35.1) 47(25.0)


statistical significance, yet many studies have demonstrated asignificant association and found that women with more ad-vanced educational attainment have a higher frequency ofhaving cervical cancer screening.19 Another factor we lookedat was the total family income, which we found to be signif-icantly associated with the likelihood of women undergoing aPap smear test at least once in their lifetime. Our results wereconsistent with a study that found family income to be animportant predictor of women’s participation in cervical

cancer screening20 and suggested that access to screeningprograms may be reduced by cost obstacles.20 Nonetheless,this may not be the case in Kuwait, as the government pro-vides citizens with free healthcare services.

Our study demonstrated a significant association betweenthe prevalence of ever having a Pap smear and marital status.The use of Pap smears is particularly less common amongwomen who have never been married. A lower prevalence ofPap smears among women who were never married isstrongly demonstrated in western cultures as well.21,22 Takinginto consideration cultural and religious practices in Kuwait,the association between marital status and Pap smear practicecan be understood. In Arab and Muslim cultures, modestyand premarital virginity are highly valued. In addition,married, divorced, and widowed women may receive morefrequent obstetrical and gynecological care. Hence, thesewomen are more likely to obtain Pap smears.18

In our study, women with either a personal or a familyhistory of cancer have a slightly higher prevalence of everhaving a Pap smear compared with other women, but the

Table 4. Association between Selected Factors

and Willingness to Participate in Screening

Program among Women Attending Polyclinics

in Kuwait (n¼ 299)

Variable

Willingness toparticipate in the

program (%) p value

Age (years)15–19 17(70.8) 0.51020–29 75(84.3)30–39 82(75.9)40–49 45(80.4)�50 12(66.7)

GovernorateFarwanya 59(83.1) 0.621Hawalli 59(79.7)Ahmadi 56(76.7)Capital 59(74.7)

Marital statusNever been married 33(78.6) 0.958Married 179(78.5)Divorced=widowed 19(76.0)

Age at first marriage<20 68(73.9) 0.63120–24 77(89.5)25–29 18(69.2)�30 7(77.8)

NationalityKuwaiti 165(77.1) 0.251Non-Kuwaiti, Arab 51(79.7)Non-Kuwaiti, non-Arab 16(94.1)

EducationNo formal education=

primary school10(62.5) 0.014

Intermediate school 27(71.1)High school 68(74.7)Diploma 61(84.7)University degree or higher 65(83.3)

Employment statusCurrently employed 113(85.0) 0.033Unemployed=student 83(71.6)Retired 33(75.0)

Combined family income (KD=month)<500 64(84.2) 0.036500–999 101(77.7)1000–1499 45(81.8)�1500 18(60.0)

Number of marriages1 170(79.4) 0.547�2 27(75.0)

Knowledge scoreLow 77(74.8) 0.067Moderate 82(75.9)High 74(86.0)

Table 5. Distribution of Women by Constructed

Index for Knowledge, Attitude, and Prevalence

of Pap Smear Screening in Respondents

Total %

KnowledgeHigh 105 34.5Medium 110 36.2Low 89 29.3

Willingness to participate in screening programYes 230 78.8No 62 21.2

Wanting to know more about Pap smearYes 240 81.4No 55 18.6

Lifetime prevalence of Pap smearYes 111 37.1No 118 62.9

FIG. 1. The prevalence of ever having a Pap smear in someselected countries.


variation did not reach statistical significance. The sample sizemay not be big enough to detect small differences. Never-theless, a U.S. study linked a personal history of cancer with alower rate of cervical cancer screening.19

Knowledge of cervical cancer and Pap smear was docu-mented as a determinant of women’s participation in cervicalcancer screening programs in developed countries.20 Ourfindings, however, demonstrated that women were not wellinformed about cervical cancer regardless of Pap smear status.This is consistent with reports from the Middle East addres-sing this issue.21 In a cross-sectional study conducted in Jor-dan, about 77% of the 600 participants were unfamiliar withthe causes of cervical cancer.12

Women participating in this study showed poor knowledgeof the major symptoms of cervical cancer, which shows theimportance of establishing a comprehensive educational pro-gram on cervical cancer and Pap smear. In this study, we werealso interested in assessing the knowledge level about the riskfactors of cervical cancer. We found that most women werefamiliar with cervical infection as a risk factor. In contrast,studies from the United States,22 U.K.,23 and Australia24 re-ported that having multiple sexual partners was the mostcommonly identified risk factor for cervical cancer. Women inKuwait, like their western counterparts, were well informed ofthe link between the number of sexual partners and cervicalcancer. This may be related to cultural beliefs that favor earlymarriage and, therefore, early sexual intercourse. Moreover,most women in such cultures have only one lifetime sexualpartner. Thus, in this context, early sexual intercourse may notbe a major risk factor.

The association between the prevalence of the Pap smearand the awareness of cervical cancer among women has beenof interest to public health providers. Our results showed thatthe level of knowledge about cervical cancer is significantlyassociated with the tendency of women to undergo Pap tests.In this aspect, our results are similar to those of a study thatshowed the awareness of cervical cancer was greatest amongthose who obtained regular smears.25 Nonetheless, becausethis is a cross-sectional study, establishing a causal relation-ship between the level of knowledge women have aboutcervical cancer and the lifetime prevalence of the Pap smear isnot possible.

The available literature demonstrates that younger womenare substantially better informed about cervical cancer and thePap smear.25 However, we were not able to detect a statisti-cally significant association. Nonetheless, we noticed that theknowledge score decreases with increase in age. This obser-vation is consistent with a study by Yu et al.,25 where differ-ences in knowledge could not be detected between the youngand older age groups. We also could not find any evidence tosuggest a relationship between family income and knowledgelevel of cervical cancer. One study,26 however, was able todemonstrate that awareness of cervical cancer is substantiallygreater among women with higher total income. They arguedthat women with a good economic status have access to betterhealthcare, which could cause a higher knowledge level aboutcervical cancer.

Surveys in both North America and Australia suggestedthat women who were never married are less well acquaintedwith cervical cancer and the Pap smear,27,28 yet we were notable to detect a correlation between marital status andawareness of cervical cancer and Pap smear among the par-

ticipants. On the other hand, we were able to demonstrate astatistically significant association between women’s educa-tional attainment and their knowledge of cervical cancer. Si-milar results were found in a study reporting that education isthe most important predictor of knowledge about cervicalcancer and Pap smear among Armenian=Lebanese women.9

Women who participated in our study identified physi-cians to be the primary source of information on cervicalcancer and Pap smear. Our observation corresponds with thefindings reported by studies from Singapore and the West,where recommendations by physicians are strongly linked tobetter adherence to the screening program and awareness ofcervical cancer.16,29,30 These findings suggest that the role ofphysicians, particularly general practitioners, in promotingcervical cancer screening among women and providing themwith the necessary knowledge deserves greater attention.Further studies are warranted to investigate the role of phy-sicians in providing knowledge about cervical cancer and Papsmear to women in Kuwait.

Previous reports suggest that patients favor physicians ofthe same sex; this is particularly true for female patients and inclinical situations requiring rectal or genital examination.31–33

In addition, women showed more satisfaction with femaledoctors than with male doctors.34 Similar to these studies, thewomen we interviewed expressed a preference for havingfemale physicians to administer a Pap test. Our results arecomparable to a number of studies from both the Westerncountries and East Asia. For instance, a large study involving97,962 women35 demonstrated that women are more likely toundergo screening with Pap smear and mammograms if theyare seen by female rather than male physicians. Another studyreported that screening administered by female doctors ismore acceptable to Chinese women.36 Our findings were alsocongruent with studies addressing this issue in the Arab andMiddle Eastern countries. Women in Jordan demonstrated ageneral preference for female physicians.12 We attribute suchfindings to cultural and religious beliefs in this region of theworld.

To develop a proper screening program, it is critical to in-vestigate potential barriers that may affect adherence toscreening. Interestingly, in our study, the majority of womenperceived no barriers to prevent them from undergoing cer-vical cancer screening, although we also found that embar-rassment and pain are the most commonly perceivedobstacles to screening. Our findings were consistent withthose of a study conducted in Australia involving women ofdifferent ethnic groups.37 They reported that women whoidentified embarrassment as a barrier were seven times lesslikely to be screened, and most of them were of Arab origin.The importance of embarrassment as a barrier to screeningwas also highlighted in a study of 350 UAE teachers.17 Thissense of unease may be related to various cultural and reli-gious beliefs.

Our findings should be interpreted in light of a number oflimitations. This study included all geographical regions ofKuwait, although Jahra and Mubarak Al-Kabeer governor-ates, which are more rural than other governorates, were ex-cluded for practical reasons; as a result, the prevalence of everhaving a Pap smear may be overestimated. Our findings arealso based on a selective group of women attending publicpolyclinics in the daytime, and we might have missed thoseattending the private sector and evening clinics. Thus, we


have to be cautious in generalizing our findings. A potentialbias in this study is the inclusion of only women who wereliterate and able to complete a questionnaire in Arabic orEnglish. Consequently, we might have excluded a part of thepopulation that might be underserved and should be targetedif a screening program were to be established. Finally, andmore importantly, the questionnaire did not ask aboutwomen’s sexual practices or smoking status because these aresensitive issues to tackle in the Middle Eastern culture, eventhough they are predictors of the risk for developing cervicalcancer.

Conclusions

Evidence shows that cervical cancer screening programshave contributed to its decreased incidence and mortality.Better knowledge about cervical cancer and Pap smear wasassociated with increased rates of Pap smears, yet women ingeneral were inadequately informed, a challenge that needs tobe addressed by healthcare providers and planners. More-over, more attention should be paid to the role physicians mayplay in the promotion of Pap smears and awareness of cer-vical cancer. One important implication of our study is havingmore female physicians, as this appears more acceptable tofemale patients. Public health policymakers and healthcareplanners need to consider developing cervical cancer screen-ing programs that meet the particular needs of women in theregion. We recommend further research in this area not onlybecause of the unique social, religious, and cultural norms ofmarriage and sexual partnership in Kuwait but also becausethere is a paucity of information related to women’s health inthe region.

Disclaimer Statement

The authors have no conflicts of interest to report.

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Address correspondence to:Lukman Thalib, Ph.D.

Department of Community Medicine and BSFaculty of Medicine, Kuwait University

P.O. Box 24923Safat 13110

Kuwait

E-mail: [email protected]


use of and attitudes and knowledge about pap smears among women in kuwait

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