Knowledge and attitudes regarding cervical cancer among adult Kuwaiti women: A cross-sectional study

Abstract

Cervical cancer is a significant public health issue, mostly caused by infection with high-risk human papillomavirus (HPV). To evaluate the knowledge and attitudes regarding cervical cancer among women in Kuwait aiming to identify knowledge gaps that may inform future prevention and early-detection strategies. Materials and Methods: A cross-sectional study conducted from February 2024 to August 2024, with 350 female employees recruited using a total population sampling approach from the Public Authority for Applied Education and Training in Kuwait. Data were gathered utilizing a verified digitally disseminated questionnaire. The analysis utilized the Pearson chi-squared test, incorporating additional degrees of freedom, using Cramér’s V as the effect size metric. The research adhered to the STROBE reporting standards. The survey encompassed 350 female employees from the Public Authority for Applied Education and Training in Kuwait. 62.2% (n = 218) were over the age of 30. 53.7% (n = 189) of the people who answered the survey were married. A total of 26.8% (n = 94) of the participants said they had more than three children, and 59.8% said they had at least a bachelor’s degree. A large majority (85.8%) knew about cervical cancer. Still, more than half (55.2%) didn’t know that the cause was a virus. 76% of people knew about the Pap smear for early detection, but it’s intriguing that 71% of married people said they had never had the test. Vaccination data showed a low rate of prophylaxis, thus, even while participants know a lot about the HPV vaccination, very few of them get it (around 15%). The sample analyzed demonstrated positive attitudes: 66% agreed on the significance of future screenings, while 48.2% conveyed optimism for forthcoming immunizations. There exists a notable divergence between public awareness and clinical participation among educated women in Kuwait. Public health campaigns must progress beyond broad awareness to address deficiencies in HPV etiology and obstacles to vaccine uptake.

Introduction

Cervical cancer continues to be a significant global public health issue and is among the most preventable cancers in women. In 2020, the World Health Organization (WHO) reported over 500,000 cervical cancer diagnoses among women, leading to more than 342,000 deaths¹. To ensure that women with cervical disease receive appropriate treatment and to prevent potentially avoidable mortality, screening programs must be precise and effective^1,2.The overwhelming majority of occurrences are linked to chronic infection with high-risk human papillomavirus (HPV), now acknowledged as the causative agent in over 99% of cervical cancer instances³. In 2020, the World Health Assembly ratified a global initiative to eliminate cervical cancer as a public health threat. The World Health Organization (WHO) supported the 90-70-90 eradication approach, which mandates 90% HPV vaccination coverage for girls aged 15, 70% screening coverage with high-performance tests at ages 35 and 45, and treatment for 90% of eligible women. This approach has the potential to preserve over 62 million lives in the forthcoming century¹. Cervical cancer is increasingly recognized as a preventable condition through the routine screening and vaccination of at-risk persons. A better understanding of disease’s natural history has led to substantial changes in the rules for screening. Some of the significant changes are starting screenings at an older age, lengthening the time between tests, and putting HPV testing ahead of cytology^4,5. The WHO now says that testing based on HPV-DNA is the best way to do so because it is objective and can find high-risk genotypes before lesions form⁵.The American Cancer Society (ACS) says that people should get primary HPV testing every five years starting at age 25⁶.Vaccination is effective and safe for individuals aged nine and above; nevertheless, vaccinated women must continue to adhere to established screening protocols^7,8.The HPV vaccine is a key way to stop certain high-risk HPV strains, especially types 16 and 18, from spreading. These strains are the main cause of cervical cancer. It works best when given before a person has intercourse for the first time. Its effectiveness is confined to particular types and does not reduce the risk posed by non-vaccine HPV strains. Information indicates that vaccinated individuals must continue regular testing. Post-market surveillance has not identified any credible side effects, showing that these vaccinations are relatively safe⁸. Women aged 13 to 26 who have not previously been vaccinated or completed the whole immunization series should receive a catch-up vaccination⁸. Despite improvements in screening technologies and the availability of effective prophylactic vaccines, global limitations in information and preventive measures persist. Not enough awareness leads to not enough people getting screened, delayed diagnoses, and illnesses that could have been avoided. However, data from Gulf Cooperation Council (GCC) countries are limited, and even fewer studies have explored the relationship between knowledge gaps and the current screening criteria implemented after 2020.Kuwait is one of the countries where there isn’t any current information about how informed people are about cervical cancer. 1.22 million women in Kuwait who are 15 years old or older are at risk of getting cervical cancer. Right now, it is the ninth most common cancer in women of all ages and the third most common in women aged 15 to 44⁹. GLOBOCAN’s 2022 forecasts show that the age-standardized incidence rate is about 2.8 per 100,000 women, which means there are about 53 new cases and 28 fatalities each year⁹. The Kuwait National Cancer Registry had already recorded a higher age-adjusted incidence rate of 3.4 per 100,000¹⁰. The data shows that the problem is becoming worse, with estimates saying that the number of cases would rise by 48% by 2035⁹. Previous studies in Kuwait showed that people didn’t know much about cervical cancer and didn’t get Pap smears often¹¹. However, these studies are no longer useful because they were done before the WHO and American Cancer Society (ACS) screening guidelines were changed, there was more support for HPV vaccination, and the global elimination initiative started. Consequently, there is inadequate understanding of the present attitudes of Kuwaiti women towards cervical cancer prevention, especially considering recent worldwide policy shifts and the improved availability of HPV-related information. Another deficiency in the literature concerns the populations that have been studied. Current research in Kuwait has predominantly utilized community-based or convenience samples; however, no study has investigated the knowledge and attitudes of educated working women in large institutional contexts—an impactful demographic. This is the first Kuwaiti study to use a total-population institutional sampling frame, a validated bilingual digital questionnaire, and contemporary items aligned with current global screening and vaccination recommendations. By quantifying both awareness and behavioral intentions—and finding where crucial knowledge deficits persist—this study contributes novel evidence to the national and international literature and aims to inform future prevention strategies, educational initiatives, and policy planning within Kuwait. The primary objective of this study was to assess knowledge and attitudes regarding cervical cancer among women in Kuwait and to identify knowledge gaps relevant to prevention, screening, and vaccination efforts. The findings are intended to inform future public-health planning and educational interventions, rather than to evaluate clinical outcomes.

Methodology

Study design and setting

A cross-sectional observational study was conducted among female Kuwaiti employees at the Public Authority for Applied Education and Training (PAAET), a large governmental academic institution comprising colleges, training centers, and administrative departments. Data collection occurred from February to August 2024. The study followed the STROBE reporting guidelines for cross-sectional research to ensure methodological transparency and reproducibility.

Study population and procedure

Eligibility Enumeration and Recruitment Frame;

The eligible study population was counted using official human-resources records provided by the Public Authority for Applied Education and Training (PAAET). These records indicated approximately 450 female Kuwaiti employees who met the inclusion criteria and had active institutional email accounts during the study period. All eligible individuals were invited to participate through the official PAAET email system, thereby defining the study denominator.

The study sample consisted of 350 adult female Kuwaiti citizens employed in diverse departments of PAAET.

Inclusion criteria

Participants were eligible if they met all the following criteria.

• Identified as female.

• Held Kuwaiti nationality.

• Employed at PAAET during the study period in any academic, administrative, or training department.

• Had an active institutional email address (required for survey access).

Exclusion Criteria: Employees who are not Kuwaiti and those who took part in the pilot project.

Sampling Strategy and Recruitment Procedures.

Sampling method

A total population sampling approach was used. The research team obtained official Human resources records documenting approximately 450 eligible female employees. All eligible individuals were invited to participate, forming the full sampling frame.

Recruitment and consent

Invitations were distributed via the secure institutional PAAET email system. Each message held:

• An explanation of the study objectives,

• A secure Survey Monkey link, and.

• An electronic informed consent form.

Participants could access the questionnaire only after providing digital consent. Responses were automatically anonymized and stored on a secure, access-controlled server.

Sample Size Justification

The minimum required sample size was calculated using Cochran’s formula for estimating proportions at a 95% confidence level (Z = 1.96), with an assumed prevalence of 0.50 and a margin of error of 0.05.

The calculation produced a required sample size of n = 384.16. Because the target population represented a finite number (450) of eligible employees, the finite population correction reduced the minimum required sample size to fewer than 300 participants. The achieved sample of 350 women, therefore, exceeded minimum requirement.

Study instrument (questionnaire)

The research instrument was a structured questionnaire created after a thorough evaluation of validated instruments employed in analogous studies throughout the Middle East region^11,12. It was carefully translated back and forth from English and Arabic. The phrases “HPV” and “Pap smear” were adapted to align with Kuwaiti cultural context for better comprehension among the populace. The translation and language modifications were implemented to improve conceptual clarity and align with prevalent Arabic medical terminology in regional healthcare contexts, rather than to tackle cultural sensitivity or perceived social taboos.

Questionnaire design

The questionnaire was designed to assess three distinct domains: sociodemographic characteristics, knowledge of cervical cancer and HPV, and attitudes toward screening and vaccination.

The instrument comprised three sections:

Sociodemographic characteristics (6 items)

This section collected data on age, educational level, occupational role, marital status, age at marriage, and number of children.

Knowledge of cervical cancer and HPV (18 items)

Items assessed participants’ understanding of cervical cancer etiology (including the viral role of HPV), awareness of screening methods and recommended intervals, and knowledge of HPV vaccination availability and optimal timing. Responses were recorded using “Yes,” “No,” and “Don’t know” options.

Attitudes toward screening and vaccination (4 items)

This domain evaluated participants’ intentions and perceptions regarding future cervical cancer screening and HPV vaccination for themselves and their daughters. Responses were measured using a 5-point Likert scale ranging from Strongly Disagree to Strongly Agree.

Validity assessment

Content validity was established through expert review by faculty members with expertise in nursing, public health, and women’s health, who assessed the questionnaire for relevance, clarity, and domain coverage. To ensure linguistic and conceptual equivalence, the instrument underwent forward and backward translation between English and Arabic. The phrases “HPV” and “Pap smear” were adapted to align with Kuwaiti cultural context for better comprehension among the populace. The translation and language modifications were implemented to improve conceptual clarity and align with prevalent Arabic medical terminology in regional healthcare contexts, rather than to tackle cultural sensitivity or perceived social taboos.

Pilot study and reliability

A pilot study was conducted with 20 female Kuwaiti employees to evaluate the questionnaire’s clarity, comprehensibility, and technical performance in the digital format. Feedback from the pilot participants indicated minor issues related to wording clarity and interpretation of certain response options. Consequently, Minor linguistic simplifications, clarification of response options, and rephrasing of selected items were implemented. No items were added or removed, and the underlying constructions of the questionnaire remained unchanged. Participants involved in the pilot study were excluded from the final analysis.

Internal consistency reliability; was assessed for the four Likert-scale attitudinal items using Cronbach’s alpha. The attitudinal scale showed acceptable internal consistency, with a Cronbach’s alpha coefficient of α = 0.78, showing that the items measured a coherent underlying construct.

Data collection

Data was collected using the Survey Monkey platform from February 2024 to August 2024. Upon clicking the digital link, participants encountered an electronic informed consent form. Participants might view the questionnaire solely after granting their consent. To safeguard participant privacy, responses were automatically and anonymously recorded in a secure database.

Variable definitions

To enable subgroup analysis, participants were categorized into three primary occupational classifications based on their roles within the institution: Administrative Personnel: Individuals employed in the office who manage human resources and do clerical tasks. Training Personnel: Individuals whose responsibility is to instruct others in skill development and enhancement. Academic Personnel: Faculty personnel who deliver lectures and conduct theoretical research.

The Research and Ethics Committee at the College of Nursing and the Central Research Committee of PAAET both gave their approval for the research protocol. All participants gave their informed consent electronically.

Data analysis

SPSS version 29 was used to do statistical analysis. Counts and proportions were used to summarize qualitative characteristics. Univariate Analysis: Pearson chi-square tests compared sociodemographic characteristics with knowledge/attitude responses (p < 0.05). Effect Size: Cramér’s V was used to assess the strength of correlation among categorical variables. Exploratory Interpretation: Due to the numerous comparisons (age, occupation, marital status), no formal adjustment (e.g., Bonferroni) was implemented; results are susceptible to exaggerated type1 errors and are provided as hypothesis-generating.

Due to the nature of the skip logic in the survey, denominators vary across sections. Individuals who indicated a lack of knowledge regarding the HPV vaccine were not asked about vaccine availability, optimal vaccination age, or vaccination history.

Results

Interpretative Note. All findings presented in this section describe observed associations between sociodemographic characteristics and knowledge or attitudinal outcomes. Consistent with the descriptive and comparative design of the study and in the absence of adjustment for multiple statistical comparisons, these results should be interpreted as exploratory and hypothesis -generating rather than definitive.

Participation Rate: The digital questionnaire was distributed to approximately 450 eligible female employees. A total of 350 complete responses were received, yielding a participation rate of 77%.

Sociodemographic characteristics

The study included 350 female employees from PAAET. Participants ranged in age ranged from 18 years and above, with 62.2% (n = 218) aged ≥ 30 years.

A total of 53.7% (n = 189) were married, while 33.5% (n = 117) were single. 26.8% (n = 94) of respondents having more than three children. Educational levels were generally high, with 59.8% (n = 209) holding a bachelor’s degree, 21.4% (n = 75) a master’s degree, and 9.1% (n = 32) a Ph.D. Occupationally, 41.6% (n = 145) worked in administrative roles, 33.9% (n = 119) in training departments, and 24.5% (n = 86) were academic teaching staff. Table 1 summarizes these characteristics.

Table 1.

Sociodemographic data of participants

	Overall (N=350)
Age
18-20	48 (13.9%)
21-25	54 (15.3%)
25-30	30 (8.5%)
30 years and above	218 (62.2%)
Marital Status
Married	189 (53.7%)
Single	117 (33.5%)
Divorced	40 (11.4%)
Widowed	4 (1.4%)
Age at Marriage
N-Miss	114
less than 17 years old	9 (3.8%)
17-20	51 (21.6%)
above 20 years old	176 (74.6%)
Use of birth control pills
N-Miss	69
yes	53 (18.9%)
no	228 (81.1%)
Education
N-Miss
Secondary School	34 (9.7%)
Bachelor	209 (59.8%)
Master	75 (21.4%)
Ph.D.	32 (9.1%)
Occupation
N-Miss
Administration	145 (41.6%)
Training	119 (33.9%)
Teaching	86 (24.5%)
Kids
N-Miss
none	139 (39.9%)
1	28 (8.0%)
2-3	89 (25.4%)
more than 3	94 (26.8%)

Knowledge of cervical cancer and HPV

Key Finding: General awareness is high, but specific medical knowledge (causality and screening intervals) is low.

General awareness

Overall awareness of cervical cancer was high: 85.8% (289/337) reported having heard of the disease. However, 55.2% (186/337) did not know it is caused by a viral infection (HPV). A significant association was found between participants occupation roles and their knowledge of the viral causation χ² (2) = 13.10, p = 0.001, V = 0.20 (medium effect). Teaching staff demonstrated the highest correct knowledge (59.8%, n = 49/82) relative to administrative (34.8%, n = 48/138) and training staff (46.2%,n = 54/117).

Age Differences.

Age was significantly associated with variation in knowledge responses.

• 18–20 years: 52.2% aware; only 17.4% knew HPV is the cause.

• ≥ 30 years: 94.3% aware; 42.9% knew HPV is the cause.

Age differences were statistically significant:

• General awareness: χ² (3) = 60.01, p < 0.001, V = 0.42 (large effect).

• Knowledge of viral etiology: χ² (3) = 19.51, p < 0.001, V = 0.24 (medium effect).

These findings reflect group-level differences based on chi-square comparisons and do not represent correlation analysis or formal assessment of health literacy. Marital status was associated with cervical-cancer awareness. Among respondents who answered the awareness item, married women indicated that they had heard of cervical cancer, compared with lower proportions among single and previously married participants. [94.0% (171/182); p < 0.001]

Screening knowledge (pap smear)

Awareness of the Pap smear was widespread, yet clinical uptake was low. A Total of 76.2% (243/319) had heard of the test. Most respondents recognized that a single Pap smear is insufficient (75.2%, n = 228/303), though only .2%(n = 43/303) correctly identified the recommended 3-year interval for cytology-based screening. Knowledge of screening intervals varied by occupation: χ² (10) = 34.71, p < 0.001, V = 0.24 (medium effect).

Screening uptake (practice gap)

Screening Uptake (Practice Gap).

Key Finding: A significant “practice gap” exists—awareness does not equal participation.

Despite high awareness, 71.3% (216/303) reported never undergoing a Pap smear.

Occupation association with screening: A significant difference existed by occupation: χ² (2) = 9.18, p = 0.010, V = 0.17 (small–medium effect).

• Teaching staff: 42.3% uptake.

• Training staff: 27.7%.

• Administrative staff: 22.1% Table 2 shows the details of these results.

Table 2.

Knowledge of Participants Regarding Cervical Cancer in Relation to Their Position in PAAET (N = 350).

Variable	Administration (n = 145)	Training (n = 119)	Teaching (n = 86)	Total (N = 350)	χ² (df)	p	V
Heard of cervical cancer?					0.38 (2)	0.829	0.03
N-Miss	7	2	4	13
Yes	118 (85.5)	102 (87.2)	69 (84.1)	289 (85.8%)
No	20 (14.5)	15 (12.8)	13 (15.9)	48(14.2%)
Is it possible that this cancer is due to an infection?					13.10 (2)	0.001	0.20
N-Miss	7	2	4	13
Yes	48 (34.8)	54 (46.2)	49 (59.8)	151(44.8)
No	90 (65.2)	63 (53.8)	33 (40.2)	186 (55.2)
Have you ever heard of early detection of cervical cancer (Pap smear)?					2.34 (2)	0.310	0.09
N-Miss	10.0	10.0	11.0	31.0
Yes	101 (74.8)	80 (73.4)	62 (82.7)	243(76.2)
No	34 (25.2)	29 (26.6)	13 (17.3)	76 (23.8)
Is it enough to perform the test (Pap smear, cytology) only once for early detection?					1.88 (2)	0.391	0.08
N-Miss	14	18	15	47
Yes	37 (28.2)	24 (23.8)	14 (19.7)	75(24.8)
No	94 (71.8)	77 (76.2)	57 (80.3)	228 (75.2)
Within what time frame should the pap smear(cytology) be repeated?					34.71 (10)	< 0.001	0.24
N-Miss	14.0	18.0	15.0	47.0
Every 10 years	5 (3.8)	3 (3.0)	1 (1.4)	9 (3)
Every 5 years	15 (11.5)	14 (13.9)	13 (18.3)	42 (13.9)
Every 3 years	8 (6.1)	12 (11.9)	23 (32.4)	43(14.2)
Every 2 years	13 (9.9)	15 (14.9)	7 (9.9)	35 (11.6)
Every year	43 (32.8)	25 (24.8)	12 (16.9)	80 (26.4)
Don’t know	47 (35.9)	32 (31.7)	15 (21.1)	94 (31.0)
Have you done the Pap test before?					9.18 (2)	0.010	0.17
N-Miss	14.0	18.0	15.0	47
Yes	29 (22.1)	28 (27.7)	30 (42.3)	87 (28.7)
no	102(77.9)	73(72.3)	41 (57.7)	216 (71.3)

Note. Values are presented as n (%). χ² = Chi-square statistic; df = degrees of freedom; V = Cramér’s V effect size. Effect size interpretation: V < 0.10 = negligible;0.10–0.20 = small; 0.20–0.40 = medium; V > 0.40 = large.

Age association with Screening: Screening uptake increased with age: χ² (3) = 30.71, p < 0.001, V = 0.32 (medium effect). Notably, ~ 60% of women aged 18–20 responded “Don’t know” regarding the recommended screening interval, indicating a significant informational gap among younger respondents. This highlights a significant “information vacuum” for young women entering the age of risk. Table 3 shows the details of these results.

Table 3.

Knowledge of Participants Regarding Cervical Cancer in Relation to Their Age (N = 350).

Variable	18–20 y (n = 48)	21–25 y (n = 54)	25–30 y (n = 30)	≥ 30 y (n = 218)	Total (N = 350)	χ² (df)	p	V
Heard of cervical cancer?						60.01 (3)	< 0.001	0.42
N-Miss	2	3	2	5	12
Yes	24 (52.2)	39 (76.5)	26 (92.9)	200 (94.3)	289 (85.8)
No	22 (47.8)	12 (23.5)	2 (7.1)	13 (5.7)	49 (14.2)
Is it possible that this cancer is due to an infection?						19.51 (3)	< 0.001	0.24
N-Miss	2	2	2	5	11
Yes	8 (17.4)	11 (21.6)	15 (53.6)	91 (42.9)	125 (37.1)
No	38 (82.6)	41 (78.4)	13 (46.4)	122 (57.1)	214(63.1)
Have you ever heard of early detection of cervical cancer (Pap smear)?						44.76 (3)	< 0.001	0.37
N-Miss	7	9	5	10	31
Yes	17 (41.5)	27 (60)	22 (88.0)	177 (85.1)	243(76.2)
No	24 (58.5)	18 (40.0)	3 (12.0)	31 (14.9)	76(23.8)
Is it enough to perform the test (Pap smear, cytology) only once for early detection?						1.78 (3)	0.620	0.08
N-Miss	11	14	5	17	47
Yes	10 (27.0)	13 (32.5)	6 (24.0)	46 (22.9)	75 (24.8)
No	27 (73.0)	27 (67.5)	19 (76.0)	155 (77.1)	228(75.2)
Within what time frame should the pap smear(cytology) be repeated?						31.53 (15)	0.007	0.19
N-Miss	12	13	5	17	47
Every 10years	1 (2.7)	1 (2.5)	0 (0.0)	7 (3.5)	9 (3)
Every 5 years	2 (5.4)	7 (17.5)	3 (12.0)	30 (14.9)	42(13.9)
Every 3 years	1 (2.7)	3 (7.5)	7 (28.0)	32 (15.9)	43(14.2)
Every 2 years	3 (8.1)	8 (20.0)	4 (16.0)	20 (10.0)	35(11.6)
Every year	8 (21.6)	8 (20.0)	3 (12.0)	61 (30.3)	80 (26.4)
Don’t know	22 (59.5)	13 (32.5)	8 (32.0)	51 (25.4)	94 (31.0)
Have you done the Pap test before?						30.71 (3)	< 0.001	0.32
N-Miss	12	13	5	17	47
Yes	0 (0.0)	3 (7.5)	8 (32.0)	76 (37.8)	87(28.7)
No	37 (100.0)	37 (92.5)	17 (68.0)	125 (62.2)	216 (71.3)

Note. Values are presented as n (%). χ² = Chi-square statistic; df = degrees of freedom; V = Cramér’s V effect size. Effect size interpretation: V < 0.10 = negligible; 0.10–0.20 = small; 0.20–0.40 = medium; V > 0.40 = large.

4. HPV Vaccination Awareness and Practices.

Key Finding: While knowledge of the HPV vaccine is moderate among participants, actual vaccine uptake remains exceedingly low (approximately 15%).

Vaccine awareness

Just over half (54.1%, n = 164/303) of participants aware of HPV knew a vaccine exists.

Awareness varied significantly by occupation: χ² (2) = 8.53, p = 0.014, V = 0.17 (small–medium effect).

Knowledge of vaccine availability

Among those who answered this item (46.2%, n = 162), 68.5% (n = 111/162) correctly indicated that the vaccine is available in Kuwait. Women over the age of 30 and married individuals demonstrated greater knowledge in this area (P < 0.001).

Optimal vaccination age

Only 11.1% (18/162) correctly identified the recommended vaccination age of 9–14 years.

Knowledge of optimal vaccination age differed by occupation:

χ² (6) = 16.93, p = 0.010, V = 0.23 (medium effect).

Vaccination uptake

Actual HPV vaccination rates were low: 14.8% (n = 24/162) among those aware of the vaccine.

These rates did not differ significantly by occupation (p = 0.369). Table 4 displays detailed findings regarding awareness of preventive measures.

Table 4.

Knowledge of Preventive Measures and Their Correlation with Occupation (N = 350).

Variable	Administration (n = 145)	Training (n = 119)	Teaching (n = 86)	Total (N = 350)	χ² (df)	p	V
Do you have information that the main cause of cervical cancer is viral infection?					13.11 (2)	< 0.001	0.20
N-Miss	7	2	4	13
Yes	36 (26.1)	49 (41.9)	40 (48.8)	125 (37.1)
No	102 (73.9)	68 (58.1)	42 (51.2)	212 (62.9)
How to get infected with this virus?					25.56 (6)	< 0.001	0.21
N-Miss	25	10	12	47
Don’t know	75 (62.5)	62 (56.9)	22 (29.7)	159(52.5)
Sexual contact	25 (20.8)	26 (23.9)	26 (35.1)	77(25.4)
Skin contact	0 (0.0)	3 (2.8)	0 (0.0)	3 (1.0)
Both	20 (16.7)	18 (16.5)	26 (35.1)	64 (21.1)
Is there a vaccination against this virus?					8.53 (2)	0.014	0.17
N-Miss	25	10	12	47
Yes	54 (45.0)	61 (56.0)	49 (66.2)	164 (54.1)
No	66 (55.0)	48 (44.0)	25 (33.8)	139 (45.9)
Is this vaccination available in Kuwait?					4.67 (4)	0.127	0.12
N-Miss	91	59	38	188
Yes	34 (63.0)	39 (65.0)	38 (79.2)	111 (68.5)
No	2 (3.7)	0 (0.0)	0 (0.0)	2.0 (1.2)
Don’t know	18 (33.3)	21 (35.0)	10 (20.8)	49 (30.2)
What is the optimal age for vaccination?					16.93 (6)	0.010	0.23
N-Miss	91	59	38	188
Don’t know	21 (38.9)	26 (43.3)	16 (33.3)	63(38.9)
9–14 years	5 (9.3)	3 (5.0)	10 (20.8)	18(11.1)
15–20 years	9 (16.7)	16 (26.7)	17 (35.4)	42 (25.9)
21–30 years	19 (35.2)	15 (25.0)	5 (10.4)	39 (24.1)
Have you ever been vaccinated against cervical cancer?					2.00 (2)	0.369	0.11
N-Miss	91	59	38	188
Yes	7 (13.0)	7 (11.7)	10 (20.8)	24(14.8)
No	47 (87.0)	53 (88.3)	38 (79.2)	138 (85.2)

Note. Values are presented as n (%). χ² = Chi-square statistic; df = degrees of freedom; V = Cramér’s V effect size. Effect size interpretation: V < 0.10 = negligible; 0.10–0.20 = small; 0.20–0.40 = medium; V > 0.40 = large. HPV = Human Papillomavirus.

Due to purposeful skip logic and variable item-level missingness, denominators differ across knowledge outcomes. Vaccine-related items were shown only to participants aware of the HPV vaccine, and screening-interval items apply only to respondents completing that section. Therefore, proportions reflect the relevant eligible subset and should be interpreted accordingly Table 5.

Table 5.

Attitude of participants towards future screening and vaccination

Do you think it is necessary to do screening in the future?
N-Miss	47.0
strongly disagree	4 (1.3%)
disagree	15(5.0%)
don’t know	84 (27.7%)
Agree	133(43.9%)
Strongly agree	67(22.1%)
intention of being vaccinated in the future?
N-Miss	188
Strongly disagree	8.(4.9%)
Disagree	17.(10.5%)
Don’t know	44(27.2%)
Agree	61(37.7%)
Strongly agree	32(19.8%)
If you had a daughter, would you be sure to vaccinate her against HPV?
N-Miss	188
Strongly disagree	6(3.7%)
Disagree	14(8.6%)
Don’t know	41(25.3%)
Agree	65 (40.1%)
Strongly agree	36(22.2%)

Shortcomings in Professional Acumen: Fig. 1 illustrates the relationship between professional duties and specific knowledge deficiencies, highlighting the distribution of critical health domains—namely HPV etiology, transmission mechanisms, and optimal vaccination administration timing—classified by occupational category. Comparative research reveals that teaching staff possess better health literacy on the viral etiology of cervical cancer compared to administrative and training groups, yet significant knowledge gaps persist throughout the entire sample. A notable deficiency was observed about the optimal age for HPV vaccination, with proficiency being insufficient regardless of professional designation. These observed differences in knowledge across occupational groups reflect variation in individual awareness rather than differences in institutional training or protocol implementation. These findings cannot be interpreted as evidence of the presence or absence of cervical-cancer prevention protocols within specific departments or academic disciplines. The results simply indicate that knowledge gaps are unevenly distributed across occupational categories, warranting targeted educational outreach.

Fig. 1.

Knowledge Gaps in HPV and Vaccination across Occupational Groups.

Knowledge Disparities Associated with Age: Fig. 2 depicts the correlation between knowledge gaps and age, emphasizing numerous significant observations. Knowledge levels generally increased with age, with both the 25–30 and ≥ 30-year groups showing higher proportions of correct responses than younger participants across most domains. In contrast, the 18–20 age demographic exhibits a significant deficiency in knowledge, especially about the ideal age for vaccination (0% awareness).

Fig. 2.

Knowledge Gaps in HPV and Vaccination across Age Groups.

Perpetual Clinical Misunderstanding: The appropriate age for immunization remains the most poorly comprehended information across all age groups.

Attitude of participants towards future screening and vaccination

Future Screening Intentions.

Among respondents, 66% (200/303) agreed or strongly agreed that future screening is necessary, while 27.7% were uncertain.

Vaccination Intentions.

Among vaccine-aware respondents:

• 57.4% (n = 93/162) intended to get vaccinated.

• 62.3% (n = 101/162) intended to vaccinate their daughters.

A substantial “Don’t know” proportion persisted (25–27%), indicating hesitation or lack of sufficient information.

Comprehensive frequency distributions for various attitudinal indicators are presented in Table 5. Figure 3 employed stacked Likert bar plots to visually assess the intensity of attitudes concerning the necessity of HPV vaccination and screening by illustrating the distribution of responses. The data reveals a clear trend toward consensus; nonetheless, a substantial proportion of participants selected ‘Don’t know’ regarding future screening and vaccination decisions. These neutral responses suggest areas where informational gaps may exist; however, the cross-sectional nature of the data does not allow conclusions about how attitudes might translate into future behaviors. Accordingly, the findings should be interpreted as highlighting potential targets for future health-education efforts, rather than as evidence that such efforts would directly lead to increased health-seeking behavior.

Fig. 3.

Participant Attitudes Towards Screening and Vaccination.

Assessment of non-response bias

Individual-level data for non-respondents were not available; therefore, formal statistical assessment of non-response bias could not be conducted. However, respondents represented all major occupational categories within PAAET, with distributions comparable to institutional staffing profiles. This suggests that large structural non-response bias is unlikely, although it cannot be fully excluded and should be considered when interpreting the findings.

Data Missingness: A missingness study was conducted to guarantee transparency concerning data integrity, illustrated through a frequency bar chart depicting non-responses for each variable (Fig. 4). The research reveals a hierarchical framework of data completeness. General awareness measures, including “Heard of Cervical Cancer” and “Viral Etiology,” had very few missing responses (approximately 3.7%), which shows that people were very interested in the important issues. On the other hand, there was a substantial amount of missing data (13.4%) for questions that needed specific technical expertise, like the frequency of Pap smears and the transmission of HPV. The significant rise in missing data (53.7%) regarding vaccine availability in Kuwait, recommended vaccination age, and individual vaccination status is mostly due to the implementation of survey skip logic. The items were provided based on previous responses to determine the data’s relevancy. This “functional missingness” is due to the way the instrument was built, not because participants didn’t follow the rules. During statistical analysis, the denominators were changed to keep the findings legitimate.

Fig. 4.

Missingness Plot: Data Completion per Variable.

Discussion

This study offers current evidence regarding knowledge, attitudes, and preventive practices concerning cervical cancer among a substantial cohort of educated Kuwaiti women employed at an important national academic institution. Even while a lot of people knew about cervical cancer, there were still big gaps in their understanding on what causes it, how to get screened, and vaccines. These inadequacies, coupled with a substantial disparity between awareness and involvement in screening or vaccination, highlight persistent challenges that endure even among relatively educated populations. These findings are incredibly helpful for figuring out how to stop the disease from spreading in the future because Kuwait doesn’t have full countrywide screening and HPV immunization programs. To stop cervical cancer from spreading over the world, it is vitally crucial to find precancerous lesions immediately and start vaccination procedures¹³. The WHO’s 90–70–90 goals say that by 2030, 90% of girls should be fully vaccinated by the time they are 15, 70% of women should undergo high-performance testing for cervical cancer at ages 35 and 45, and 90% of women who are diagnosed with cervical illness should obtain treatment³. To promote early detection of cervical cancer, it is essential to enhance awareness and attitudes regarding the improvement of clinical practices. (e.g., cervical cancer screening and vaccination)¹⁴. This study provides an initial assessment of cervical cancer awareness and preventive strategies among a highly educated cohort of female employees in Kuwait. Our findings indicate a significant “action gap”: despite extensive awareness of cervical cancer, the implementation of Pap tests and HPV vaccination remains critically insufficient. This difference shows that having a comprehensive education and general knowledge is not enough to encourage this group to practice preventive health.

Knowledge–practice discrepancy

Despite 85.8% of participants having heard of cervical cancer, only 28.7% (87/303) of respondents who answered the Pap test question reported having undergone screening, indicating low uptake overall-mirroring findings from previous Kuwaiti research in which 23.8% of women had ever been screened¹¹.Comparable patterns have been documented across the Gulf, including Qatar¹⁵ and the UAE¹⁶, where knowledge is often considerably higher than screening uptake. This mismatch suggests that information alone does not translate into preventive behavior. Structural, cultural, and attitudinal limitations undoubtedly affect decisions for screening. These include the lack of regular national programs, misunderstandings about screening intervals, and a low sense of personal risk. We need to keep these contextual limits in mind while trying to understand the practice gap seen in this institutional cohort. A major problem that this study found is the “one-and-done” myth, which says that approximately 30% of women of all ages wrongly believe that one Pap smear will protect them for life. Furthermore, just 14.2% correctly named the recommended three-year screening interval for cytology examination. This lack of longitudinal understanding (p = 0.620) poses a significant threat to the WHO’s 90-70-90 target, which requires 70% of women to undergo high-performance screening by ages 35 and 45³.

The viral link and the “information vacuum”

A striking finding was the limited understanding of HPV as the primary causal agent of cervical cancer. More than half of respondents (55.2%) did not identify cervical cancer as a virus-related disease. This “information vacuum” is especially evident among younger individuals (ages 18–20), only 17.4% of whom correctly recognized viral causation. In contrast to these findings, a study from Uganda, where 83.8% of the studied women accurately specified the association of HPV infection with cervical cancer¹⁷ on the other hand, findings of an Omani study revealed comparable deficiencies in viral literacy¹⁸. The inconsistency across settings emphasizes the necessity of targeted educational interventions that address HPV transmission, natural history, and the rationale for early vaccination. At a time when global initiatives emphasize HPV elimination, limited etiologic awareness directly undermines vaccine acceptance and screening uptake.

Screening literacy and persistent misconceptions

Although three-quarters of participants knew about Pap smears, only 14.2% correctly identified the recommended three-year screening interval for cytology-based testing. Across all age groups, 22–32% believed a single Pap smear offers lifetime protection, a misconception that significantly undermines adherence to repeated screening. Younger women displayed the highest levels of uncertainty, with nearly 60% responding “Don’t know” regarding recommended intervals. These findings suggest that even among highly educated populations, individuals often fall to internalize knowledge of screening frequency and its rationale. Because the WHO’s elimination framework requires 70% screening coverage at ages 35 and 45, addressing interval-related misconceptions should be a priority for national health outreach.

HPV Vaccine awareness and uptake

While 54% of respondents recognized the existence of an HPV vaccine, only 14.8% had been vaccinated. This is consistent with regional literature showing high theoretical acceptance but low actual uptake Misunderstanding the appropriate age for vaccination was widespread—only 11.1% correctly identified the recommended age range of 9–14 years. Such misconceptions may contribute to perceived irrelevance among adults and parents. This study did not directly assess constructs such as complacency or belief in conspiracy theories; therefore, the low vaccination uptake in this cohort may be attributed to various other factors, including logistical challenges or insufficient healthcare provider recommendations, necessitating further qualitative inquiry. Prior Middle Eastern research suggests these factors may influence decision-making¹⁹. It is important to note that within Middle Eastern populations, there is a prevalent cultural hesitancy regarding HPV-related diseases, where vaccine conspiracy theories and a low perceived risk of infection are common^20–22. The high proportion of “Don’t know” responses about future vaccination also signals uncertainty and the need for structured, evidence-based public health messaging. Our data showed a considerable degree of general awareness alongside a minimal inclination to vaccinate; nevertheless, the factors causing this disparity to require further clarification.

Sociodemographic and occupational variations

Consistent with other regional studies, older women demonstrated higher levels of cervical cancer awareness, greater understanding of risk factors, and higher screening uptake²³. Occupational differences also emerged: teaching staff had significantly better etiologic knowledge and higher Pap smear completion rates compared with administrative employees. These differences should not be interpreted as evidence of institutional differences in training, but rather as reflections of individual education levels, access to health information, or health-seeking behaviors. Nevertheless, identifying subgroups with lower literacy—especially administrative staff and younger women—provides direction for designing targeted institutional health promotion programs.

It is important to note that observed associations between occupation and knowledge outcomes reflect group differences based on unadjusted chi-square tests and may be confounded by other characteristics.

Comparison with findings from other countries should be interpreted cautiously. While studies from Kuwait, Qatar, the UAE, and Oman have similarly reported limited cervical-cancer knowledge or low uptake of Pap testing and HPV vaccination, these results reflect descriptive prevalence rather than shared cultural or behavioral determinants. The present study’s findings—particularly the gaps in awareness of viral etiology, screening intervals, and optimal vaccination age—align with patterns described in certain regional studies, but the available evidence does not permit inferences about Middle Eastern cultural norms or broader societal drivers. Variation across countries in published research likely reflects differences in study design, sampling frames, population characteristics, and health-system structures rather than a uniform regional pattern. Accordingly, our findings should be understood as institution-specific observations that parallel, but do not generalize to, results reported elsewhere. Future research using standardized instruments across multiple settings would be required to determine whether the knowledge gaps identified here are consistent across the region or are localized to specific subpopulations.

Future Opportunities for Intervention

The findings present a “window of opportunity” despite the existing practice gap. 66% of the people who took part indicated they realized that screening would be needed in the future, and 62.3% said they would be willing to vaccinate their daughters. Given the high level of education in this cohort (90% have a bachelor’s degree or higher), evidence-based messaging that goes from “General Cancer Awareness” to “Actionable HPV Prevention” could close the gap between what people know and what they do.

Strengths and limitations

Strengths:

• Novelty and Geographic Specificity: This study provides crucial data on HPV awareness and screening uptake specifically in the Kuwaiti context, where such information is generally scarce.

• Sample Size and Diversity: The study’s sample size of 350 is significant and originates from a notable public authority. It has persons with a wide range of education levels, from high school to Ph.D. holders.

• Concentrate on a particular, under-researched demographic.

• Limitations:

• Cross-Sectional Design: The study’s cross-sectional design inhibits the identification of temporal or causal relationships among variables. We can identify correlations between variables (e.g., age and knowledge), but we cannot confirm that enhanced information resulted in a change in attitude.

• Limited Generalizability: These results offer an interesting perspective on an educated group, but they cannot be generalized to the larger Kuwaiti population (1.2 million Kuwaiti females) due to the sample being educated, employed women from a single public body. Consequently, the results may not accurately reflect the whole female demographic in Kuwait, especially among those residing in rural regions or with lower educational qualifications. This limitation has a big effect on school and job choices, and it also adds to the “healthy worker” bias. Consequently, the results have to be seen as institutional-employee findings rather than indicative estimates for the total population of Kuwaiti women. Subsequent study ought to integrate community-based sampling to facilitate a more thorough national assessment.

• Social desirability bias and dependence on self-reported data: The results were obtained from a digitally disseminated questionnaire, perhaps influenced by recall bias or social desirability bias concerning screening behaviors. Participants can have exaggerated positive attitudes or previous screening actions to conform to perceived health norms.

• Heightened probability of Type-I errors due to the augmented number of statistical comparisons. Although we saw significant discrepancies among various demographic groups, these findings are preliminary and necessitate validation through larger, longitudinal studies.

Conclusion and future scope

Participants in this study demonstrated broad awareness of cervical cancer but lacked several critical components of preventive knowledge—specifically, understanding of HPV as the etiologic agent, the recommended timing of HPV vaccination, and appropriate intervals for Pap smear screening. Despite generally positive attitudes toward prevention, actual engagement in screening and vaccination was low. These findings reflect a descriptive knowledge–practice gap within a single institutional cohort rather than causal or predictive relationships. Given the cross-sectional design and reliance on unadjusted bivariate analyses, the present results should be interpreted as exploratory indicators of potential barriers rather than as evidence supporting specific intervention pathways. Accordingly, any implications for workplace programming or broader public-health initiatives remain hypothetical. The findings identify domains where informational deficits are concentrated, but they do not demonstrate that targeted educational interventions would directly increase screening uptake or vaccination behavior. Future research should employ community-based sampling and multivariable statistical modeling to determine independent correlations of screening behavior and to test whether HPV knowledge mediates relationships between sociodemographic factors and preventive practices. Such analytic approaches will be essential to support more robust inferences and to inform the design of evidence-based interventions suitable for implementation at institutional or population levels.

Author contributions

N.B. and B.A. contributed to the conceptualization and design of the study. M.A. managed the data acquisition, including the distribution and collection of the questionnaires. N.B. and H.S. performed the formal statistical analysis and interpretation of the results. N.B. prepared the original manuscript draft. All authors (N.B., B.A., H.S., M.A.) critically reviewed and edited the manuscript, approved the final submitted version, and agreed to be personally accountable for their contributions and the integrity of the work.

Funding

We acknowledge the Public Authority for Applied Education and Training, Kuwait, for funding and making this research project possible (funded grant number No. CN-23-01).

Data availability

The datasets generated and analyzed during the current study are available in the Zenodo repository at the following DOI: https://doi.org/10.5281/zenodo.17488645. The data have been deposited to ensure transparency, reproducibility, and accessibility for future research purposes.

Declarations

Competing interests

The authors declare no competing interests.