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Non-Adherence to recommended Pap smear screening guidelines and its

associated factors among women attending health clinic in Malaysia

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 ORIGINAL ARTICLE

Non-Adherence to recommended Pap smear

screening guidelines and its associated factors
among women attending health clinic in
Malaysia
Yunus NA, Mohamed Yusoff H, Draman N
Yunus NA, Harmy MY, Nani D. Non-Adherence to recommended Pap smear screening guidelines and its associated factors among women
attending health clinic in Malaysia. Malays Fam Physician. 2018;13(1);10–17.

Abstract
Keywords:
Pap smear screening; non- Introduction: Cervical cancer ranks as the second most frequent cancer among women in
adherence; associated factors Malaysia. Although a cervical screening program has been introduced since 1960s and is
provided free of charge in all government health facilities, the coverage and adherence rate to
recommendation among Malaysian women remains low.
Authors:
Objectives: To determine the proportion of non-adherence to Pap smear screening guidelines and
Nor Akma Yunus its associated factors among women attending a health clinic in Malaysia.
(Corresponding author)
MD, MMed (F Medicine) Method: A cross sectional study involving 316 women aged 20 to 65 years who had undergone
Department of Family Medicine, a Pap smear. Universal sampling method was applied to select participants among women
School of Medical Sciences, Universiti who attended the selected health clinic from January 2013 to May 2013. A self-administered
Sains Malaysia (USM), questionnaire was used to obtain the socio-demographic characteristics, socio-health data and
Kubang Kerian, Malaysia. perceptions about cervical cancer and Pap smear screening. The data was analysed using descriptive
Email: [email protected] statistics and multiple logistic regression.

Result: The proportion of non-adherence to Pap smear screening was 90.5%. Age, marital status,
Harmy Mohamed Yusoff duration of marriage, education level, employment, household income and number of children were not
MD, MMed (F Medicine) significantly associated with non-adherence. Perceived severity, perceived susceptibility, perceived benefit,
Faculty of Medicine, Universiti perceived barrier and cues to action did not show significant association with non-adherence to Pap
Sultan Zainal Abidin (UniSZA) smear screening.

Conclusion: Non-adherence to Pap smear screening was high among Malaysian women. Measures
Nani Draman should be taken to increase Pap smear screening coverage in our country. Other factors beyond
MD, MMed (F Medicine) Health Belief Model that influence Pap smear screening practice among Malaysian women should
Department of Family Medicine, be explored.
School of Medical Sciences,
Universiti Sains Malaysia Introduction treatment, and follow up is conducted. A
(USM), Kubang Kerian, Malaysia. Papanicolaou (Pap) smear test, which was
Cervical cancer is one of the most important introduced in the 1940s, has the ability to
health issues among women. It is the fourth detect cervical cancer at the pre-invasive stage.4
leading cancer in women worldwide and the The extensive use of this test has produced
second most common cancer among women a tremendous reduction in cervical cancer
in Malaysia.1,2 The number of cervical cancer incidence and invasive disease in Western
patients in Malaysia in 2003 was 1557, which countries.5 Subsequently, the National Cancer
accounted for 12.9% of total female cancers. Institute of the United States reported that
Moreover, the average annual hospital admission women who have not been screened for cervical
for cervical cancer was 2000 to 3000 cases per cancer were three to ten times at greater risk
year, with the majority of them presenting with of developing invasive cervical cancer.6 Risk
a FIGO stage II or higher 3. also increases with long lapses following the
last normal Pap test or with longer screening
Despite all these alarming facts, cervical cancer intervals. As reported by Benedet et al., women
is a preventable disease when proper screening, who do not have Pap smear screening and those

10 Malaysian Family Physician 2018; Volume 13, Number 1

 ORIGINAL ARTICLE

whose interval between smears is more than One of the common theoretical models used to
3 years are at the highest risk for developing understand patients’ practices towards preventive
cervical cancer.7 behavior is the Health Belief Model (HBM). It
is a conceptual model that focuses on peoples’
A cervical cancer screening program has been perceptions about their illness, beliefs and
in place in Malaysia since the 1960s.8 The actions related to prevention of the disease, and
Ministry of Health Malaysia recommends Pap how it affects their health.13 It was created by
smear screening for all women between the psychologists at the United States Public Health
ages of 20 and 65 years old who are, or who Service in the 1950s to understand why people
have been, sexually active. If two consecutive could not accept disease preventive activities.13
yearly tests are negative, subsequent screening The model covers five domains, which are;
can be done every three years.9 The focus perceived susceptibility, perceived severity,
groups for the program are women who receive perceived benefit, perceived barrier, and cues to
family planning help or attend maternal and action. Figure 1 describes these five domains to
child health clinic.8 Although the test is widely distinguish features of each domain. It has been
available and given for free at public health extensively used as a conceptual framework in
clinics, this program has failed to achieve many health behavior studies to understand
satisfactory screening coverage and a reduction individual health beliefs and intervene in cancer
in incidences of cervical cancer due to its screening behaviors.14,15 HBM was also used in a
opportunistic nature10,11. In the last five years, local study by Baskaran et al. at the outpatient
Pap smear coverage in Malaysia remains around department of one public university hospital
22% of estimated eligible women.12 Whereas, in Kuala Lumpur to determine the correlation
among cervical cancer patients diagnosed at between demographic data and perceived
eight major hospitals in Malaysia, 48% reported susceptibility, perceived benefit, and perceived
never had a Pap test, while 95% did not have the barriers for cervical cancer screening.16
test within the last three years.3

Figure 1: Key domains in the Health Belief Model13

Perceived susceptibility:
This is the perception of one’s own personal risk of developing a particular condition, and it
involves a subjective evaluation of risk.
Perceived severity:
One’s belief of how serious a condition and its sequel are. This is the degree to which the
person attributes negative medical, clinical, or social consequences to being diagnosed with an
illness.
Perceived benefits:
One’s belief in the efficacy of the advised action to reduce risk or seriousness of impact. It is
the belief about the effectiveness of different actions.
Perceived barriers:
One’s beliefs about the tangible and psychological cost of the advised action and the
potential negative aspects of a particular action
Cues to action:
Strategies that people carry out to activate the preventive action, like publicity or bodily
events.

Cervical cancer screening is a formidable Methods

challenge in Malaysia. Lack of knowledge and
incorrect beliefs about Pap smear screening This was a cross-sectional study conducted
are among the contributing factors to poor from January to May 2013 at Klinik Kesihatan
screening uptake.10,17,18 Therefore, the purpose Bandar Kota Bharu, in Kelantan, Malaysia.
of this study is to determine the non-adherence The sample size was calculated using the
rate of Pap smear screening guidelines in single proportion formula with an assumption
Malaysia, evaluate the women’s perceptions of 40.3% non-adherence.19 A final sample
about cervical cancer and Pap smear screening, size was adjusted to 334 after factoring in a
and assess the association between their beliefs 30% non-response rate. This study used the
and Pap smear screening practice. convenience sampling method in view of the
feasibility of obtaining an adequate sample.

Malaysian Family Physician 2018; Volume 13, Number 1 11

 ORIGINAL ARTICLE

All women who attended this clinic during The HBM questionnaire was developed based
the data collection period and fulfilled the on the HBM theory to assess beliefs related to
inclusion criteria were invited to join the cervical cancer and Pap smear screening. Based
study. They were recruited by nurses who on literature reviews on factors influencing Pap
had undergone briefing and training for data smear screening practice, 50 initial items were
collection. There were four points of data identified and grouped into the five domains
collection, which were the outpatient unit, of the HBM. All items were constructed in
maternal and child unit, extended scope the Malay language because the majority of
clinic, and chronic disease unit, with one the targeted population was Malay. Series
appointed nurse at each point. The inclusion of discussions with three Family Medicine
criteria were women between the ages of Specialists were carried out to ensure good
20 and 65 years old, who had Pap smear content validity and comprehensiveness of the
screening at least once and for whom the first questions. The questions were also reviewed by
Pap smear test was done in 2008 or earlier. 15 medical officers and nurses for face validity.
Women who had history of cervical cancer A pilot study was conducted at five health
were excluded from this study. The year 2008 clinics in Kelantan, which involved 50 women
was decided as the cut-off point in order to who attended the clinics during this period.
identify women who fulfilled the definition The data was analyzed for internal consistency
of adherence. In this study, ‘adherence’ was using Cronbach’s alpha and exploratory factor
defined according to Malaysian cervical analysis to evaluate the construct validity.
cancer screening guidelines, which were that Five items were eliminated due to low factor
the interval between the first Pap test and the loading, which were ‘abnormal Pap test
second Pap test should be one year, and that leads to cancer cervix,’ ‘possibility of getting
the interval between subsequent tests after abnormal Pap test when the previous test
the second consecutive test should be every was normal,’ benefit from regular Pap test,’
three years.9 For example, a woman who had ‘Pap test was not done at closed area,’ and
her first Pap test in 2008 should have had the ‘get individual invitation to do the test.’ The
second test in 2009 and the third test in 2012 final questionnaire consisted of 45 items with
if the first two tests were normal. Therefore, Cronbach alpha and factors loading, as seen
this woman would be considered adherent. in Table 1. The questions were scored using
Women who did not follow this schedule a 4-point Likert Scale, except for the ‘cues to
would be considered non-adherent. action’ domain. For the perceived severity,
susceptibility, and benefit domains, the scoring
During the data collection period, the purpose was 4 for ‘strongly agree,’ 3 for ‘agree,’ 2 for
and conduct of the study was explained to ‘disagree,’ and 1 for ‘strongly disagree.’ The
the participants, and the confidentiality scoring was reversed for the perceived barrier
of the data was assured. One set of self- domain. Cues to action was scored with 1
administered questionnaires, which consisted for ‘Yes,’ and 0 for ‘No’ and ‘Not applicable.’
of sociodemographic data, socio-health data, The scoring is explained in Table 1. The mean
and an HBM questionnaire, was given to score for each domain was calculated for
each participant. Socio-health data provided comparison.
information about the years when the Pap test
were done to assess adherence to Pap smear
screening guidelines.

Table 1: Health Belief Model Questionnaire validation and scoring for each domain
Initial Final Factor Cronbach Minimum Maximum
Domains
items items loading alpha score score
Perceived severity 10 9 0.47 – 0.79 0.80 9 36
Perceived 9 8 0.50 – 0.88 0.82 8 32
susceptibility
Perceived benefit 7 6 0.57 – 0.84 0.94 6 24
Perceived barrier 17 16 0.48 – 0.83 0.91 16 64
Cues to action 7 6 0.59 – 0.77 0.77 0 6

12 Malaysian Family Physician 2018; Volume 13, Number 1

 ORIGINAL ARTICLE

Data entry and analysis were done using Malaysia National Medical Research Register
the SPSS software for Windows Version 20. (NMRR-12-1009-12471).
All variables with p-value less than 0.25 on
bivariate analysis and clinical importance were Results
included in the multivariate analysis. The
significance level for multivariate analysis was A total of 334 eligible women were offered
set at 0.05 with 95% confident intervals. a chance to participate in this study.
However, only 316 women agreed, giving a
This study obtained approval from the ethical response rate of 94.6%. Socio-demographic
committee of the University Sains Malaysia characteristics of the participants are shown in
(USMKK/PPP/JEPeM[252.4.(1.3)]) and the Table 2.

Table 2. Socio-demographic characteristic of the participants (n=316)

Characteristic n (%) Mean (SD)a
Age 41.2 (9.21)
Marital status
Married 305 (96.5)
Widow 11 (3.5)
Duration of marriage 17.8 (9.18)
Education level
None 4 (1.3)
Primary 14 (4.4)
Secondary 206 (65.2)
Diploma 79 (25.0)
Degree/Masters/PhD 13 (4.1)
Occupation
Employed 205 (64.9)
Unemployed 111 (35.1)
Household income
<RM1000 142 (44.9)
RM1000 – RM5000 155 (49.1)
>RM5000 19 (6.0)
No. of children 3.9 (1.85)
a
Standard deviation

Of the 316 participants, 286 women were found to be non-adherent to screening guidelines,
resulting in a prevalence of 90.5%, while 132 women (41.8%) reported having a Pap smear test
within the last 3 years (Table 3).

Table 3: Prevalence of non-adherence to Pap smear screening, and recent Pap test within 3 years
(n=316)
Outcome n (%)
Adherence to Pap smear screening guidelines
Did not adhere 286 (90.5)
Adhered 30 (9.5)
Have had a Pap test within 3 years
Yes 132 (41.8)
No 184 (58.2)

Malaysian Family Physician 2018; Volume 13, Number 1 13

 ORIGINAL ARTICLE

Health Belief Model domains ‘Perceived severity’ and ‘perceived benefit’

have the same difference, 0.41, while ‘cues to
The mean scores for all HBM domains do not action’ has a difference of 0.15. In all the afore
show a significant difference between the group mentioned domains, the group that adhered
that adhered and the group that did not, as scored higher. In comparison, the difference of
shown in Table 4. The largest difference is in the scores of the two groups for ‘perceived barrier’
‘perceived susceptibility’ domain, with merely a is 0.08 with the non-adhering group scoring
1.04 point difference between the two groups. higher than the group that adhered.

Table 4. Mean total score for Health Belief Model domains between the group that adhered and the
non-adhering group (n=316)
Mean (SD)a
Domains Non-adhering adhering 95% CI p valueb
(n=286) (n=30)
Perceived severity 27.19 (3.70) 27.60 (3.52) -0.98, 1.80 0.564
Perceived susceptibility 24.09 (2.92) 25.13 (2.37) -0.04, 2.13 0.060
Perceived benefit 19.92 (2.45) 20.33 (2.63) -0.52, 1.35 0.380
Perceived barrier 34.95 (7.69) 34.87 (8.22) -3.00, 2.84 0.957
Cues to action 4.05 (1.53) 4.20 (1.35) -0.42, 0.73 0.596
a
Standard deviation
b
Independent t-test

Simple logistic regression analysis is shown in Table 5. Multivariate analysis reveals no significant
association between sociodemographic variables and HBM domains with non-adherence to Pap
smear screening.

Table 5: Association between socio-demographic factors and non-adherence to Pap smear

screening by Simple Logistic Regression
SLRa
Variables
Crude OR (95% CI) p value
Sociodemographic variables
Age 1.00 (0.96,1.04) 0.985
Marital status
Married 1.0
Widow 0.46 (0.09,2.21) 0.329
Duration of marriage 1.01 (0.97,1.06) 0.525
Education level
None/primary 1.0 0.599
Secondary 0.49 (0.06,3.88) 0.501
Tertiary 0.71 (0.08,6.19) 0.760
Occupation 0.93 (0.43,2.03) 0.853
Household income
<RM1000 1.0 0.770
RM1000-RM5000 0.89 (0.41,1.89) 0.735
>RM5000 1.18 (0.22,14.71) 0.577
No. of children 0.98 (0.80,1.20) 0.828

Health Belief Model domains

Perceived severity 0.97 (0.87,1.08) 0.563
Perceived susceptibility 0.89 (0.79,1.01) 0.062
Perceived benefit 0.94 (0.81,1.09) 0.379
Perceived barrier 1.00 (0.95,1.05) 0.956
Cues to action 0.99 (0.98,1.01) 0.553
a
Simple logistic regression

14 Malaysian Family Physician 2018; Volume 13, Number 1

 ORIGINAL ARTICLE

Discussion Malaysian women,17,24 it might not influence

the adherence to the screening guideline, as
This study revealed a very high rate of non- evidenced in our study.
adherence to Pap smear screening among
Malaysian women (90.5%). Although there is Although it was not demonstrated in our
no previous local study on screening adherence study, prior studies showed socioeconomic
to compare with, the high non-adherence rate indicators, such as education level, income
was expected as the screening coverage in our ,and employment, influenced Pap smear
country is very low.10,12 An annual report by screening uptake and adherence.23,25 Several
the Malaysia Ministry of Health revealed that local studies also revealed that education level
national cervical screening coverage remained at and employment status were associated with
22% from 2010 to 2013 despite the availability a tendency for screening among Malaysian
of the test since 1960s.12 Meanwhile, a much women.3,16 However, intentions may not
lower non-adherence rate of 16% to 30% was always translate into practice. Women with
observed in developed countries, where the higher socioeconomic status might come in
screening coverage is much higher than in their for a Pap test, but they might not adhere to the
developing counterparts, such as Malaysia.20-22 recommended schedule, as demonstrated in our
Previous survey in 57 countries by the World study. Hence, continuous health promotions
Health Organization reported only 19% about Pap smear screening need to be regularly
screening coverage in developing countries as emphasized to all eligible women, regardless
compared to 63% in developed countries.22 of socioeconomic background, to ensure
This huge difference in screening coverage adherence.
might be an important contributing factor to
the low adherence in developing countries, HBM is a conceptual model used to explore
including Malaysia. the relationship between health beliefs and
health behaviours. This model has been used
All socio-demographic variables tested in our extensively in various health-related behaviour
study failed to show any significant association studies, such as compliance with breast cancer
with Pap smear screening adherence. Previous screening and predicting dietary habits.26,27 The
studies also showed conflicting results in use of the HBM in understanding the factors
terms of association between age with Pap influencing cervical cancer screening practices
smear screening adherence.20,21,23 Nelson et has been reported in many studies.15,28,29 but
al. and Shelton et al. failed to demonstrate a limited number of studies used this model
any association between age and adherence to to look at the association with cervical cancer
cervical cancer screening in their studies.20,21 In screening adherence. The present study used
comparison, a systematic review by Limmer et HBM as the framework to explore the factors
al. reported that there were seven studies that influencing non-adherence to cervical cancer
concluded that younger women were more screening in our population, but our findings
adherent, and that there were other studies showed contradicting results from HBM
that showed higher adherence among older principles. We found that the adherence to
women.23 The inconsistency in study findings cervical cancer screening in our population
might be due to heterogenocity in the age of was not influenced by any of the five domains
the study population and difference cut-off of the HBM. Similarly, a study among Thai
point s used in classifying age groups. women also failed to show a relationship
between perceived threat (which included
Marital status was not a significant determinant perceived susceptibility and severity), perceived
to screening adherence in our study. Similarly, benefit, and cues to action with cervical
in a previous study by Shelton et al. among cancer screening adherence.30 However, the
immigrants to the United States, it was reported former study reported a significant association
that there was an inconsistent association between ‘perceived barrier’ and cervical
between marital status with adherence across cancer screening adherence, which was not
four sub-groups of the immigrants.21 The evident in our study.30 On the other hand,
study also showed that the influence of Shelton et al. showed inconsistent association
marriage on the social role and perception of a between barriers with cervical cancer screening
women might be different across regions and adherence across four sub-groups of immigrants
ethnicities. While being married was frequently in their study.21 This discrepancy in the results
found as a significant associated factor for could be due to the barriers of concern in
cervical cancer screening uptake among one population being different from those in

Malaysian Family Physician 2018; Volume 13, Number 1 15

 ORIGINAL ARTICLE

other populations. Moreover, as reported by bias, thus decreasing the potential to generalize
Abdullah et al. in their study, the perceived the results to other populations. Furthermore,
barrier faced by Malaysian women who did not the data relied on self-reported practices of
undergo a Pap smear or did not repeat the test Pap smear screening, which might be over- or
as scheduled was minimal.29 Thus, there must under-reported by the participants. Finally,
be other factors apart from perceived barriers this study only explored women’s perception
that hinder the women from undergoing or based on HBM. There may be other important
maintaining cervical cancer screening. factors that influence screening habits which
are not covered in this model, such as system
In addition, as preventive behaviour is a factors and social norms.
complex process, factors influencing screening
habits need to be studied from various angles. Recommendation
Although HBM is useful for describing reasons
for problem from the perspective of patients’ As clearly demonstrated in this study, the
beliefs, our study and a few more studies failed proportion of non-adherence to Pap smear
to demonstrate significant association between screening among Malaysian women is high.
HBM domains and non-adherence to Pap Therefore, Pap smear screening programs
smear screening.21,30 This shows that people’s should be more proactive in order to increase
perceptions do not necessarily translate into the screening coverage in Malaysia. More
practice. Moreover, HBM theory focuses on quality indicators for screening monitoring
individuals as one unit of change, whereas are also required in our system. The number
health behaviours are effects of various levels of Pap smear samples alone is not an adequate
of influence, such as intrapersonal influence, indicator with which to monitor screening
institutional factors, community factors, and coverage. A more precise indicator, such as
public policy.31 For example, ‘subjective norms,’ ‘percentage of eligible women in the target
which are social standards and motivations to population who have Pap smears’ and
comply with those norms, are studied in the ‘percentage of eligible women who repeat the
Theory of Planned Behaviour, but not covered test after 3 years of negative Pap smear results,’
in HBM.32 Therefore, addressing issues of non- may be more meaningful in monitoring Pap
adherence in Pap smear screening might require smear screening coverage in our country. On
more than one theory, since there may be no the other hand, other factors beyond the HBM
single theory which is suitable for all cases. that influence Pap smear screening uptake in
Hence, further study is required to explore our population must be explored.
other possible factors contributing to non-
adherence to Pap smear screening guidelines. Acknowledgements

Limitations We would like to thank the Director General of

Health Malaysia for his permission to publish
Like any other study, this study is not exempt this article. Our gratitude also goes to all of the
from limitations. Firstly, a cross-sectional study participants, health clinic staff, and others who
utilizing convenience sampling might lead to lassisted with this study.

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