Limited Understanding of Pap Smear Testing among Women, a Barrier to Cervical Cancer Screening in the United Arab Emirates

Abstract

Global data indicate that cervical cancer is the fourth most common cancer among women worldwide. Important factors that affect interventions for early diagnosis of cervical cancer include social beliefs and values and poor knowledge. These may contribute to women’s participation in screening for cervical cancer and have a significant impact on decisions to take preventive action. The present study was conducted with 599 women in the UAE between September 2016 and March 2017. A cross-sectional survey was conducted to determine knowledge about cervical cancer and screening, demographic characteristics and perceived barriers. Knowledge about the Pap smear test was limited, and awareness that they should undergo the Pap smear test every three years even with an initial negative/normal Pap smear result was abysmal. In spite of the positive attitude of the women towards the Pap smear test, almost 80% of the women surveyed had no knowledge of precancerous lesions. Having higher income (21/29, 72%, p=0.027) and more miscarriages were associated with better practice of Pap smears (19/26, 73%, p=0.010). Knowledge levels were significantly higher (66.3±22.2,) that values for attitude (60.5±20.9, p= 0.03, 95% CI {0.22-11.3}, Chi-square 4.38) and practice (53.7 24.1, p= 0.001, 95% CI {6.9-18.1}, Chi-square 19.7). A well-designed health education programme on cervical cancer and benefits of screening should increase the awareness among women in UAE. One point to stress is that better communication with health professionals and improvement of access to health care services should increase the rate of cervical cancer screening.

Introduction

Cancer of the cervix is a preventable disease, as it is pre-detected by a long, treatable pre-invasive stage that can be detected with routine cervical screening, of which the Papanicolaou (Pap) smear remains the primary tool. Global data indicate that cervical cancer is the fourth most common cancer among women worldwide, with approximately 528,000 new cases and 270,000 deaths annually. About 85% of the cases are in developing countries, accounting for 13% of all female cancers (Small et al., 2017). The United Arab Emirates (UAE) have a population of 1.82 million women ages 15 years and older who might be at risk of developing cervical cancer. Like many other countries, cervical cancer in the UAE is the second commonest cancer in females. The Health Authority Abu Dhabi (HAAD, 2013) reported around 50-55 new cases annually in the Emirate of Abu Dhabi with an overall incidence of 7 per 100,000 women; half of these cases occurring in relatively young women between the ages of 35-55 years (HAAD, 2013). Other Arabian Gulf countries have also shown a similar pattern of incidence and trends in cervical cancer (Ivana Kulhánová et al., 2017; Nooyi and Al-Lawati, 2011). Interestingly, nearly 70% of cervical cancer cases are diagnosed at a later stage and are therefore not curable. Public health reports, press the urgent need to develop and execute programs towards prevention and early detection of cervical cancer in the UAE (Khan and Woolhead, 2015).

A relatively low prevalence of abnormal smears and cervical cancer has been reported in the Muslim population as compared to the Western population (Barakat and Maaita, 2002; Bener et al., 2001; Jamal and Al-Maghrabi, 2003; Wasti et al., 2004). Probable explanations include sexual behavior inherent to the practice of Islam (Jamal and Al-Maghrabi, 2003). Early detection and treatment of cervical cancer through screening programs significantly reduce the morbidity and mortality of this disease (Mosavel et al., 2009).

Important factors that affect applications for early diagnosis of cervical cancer is shown to be social beliefs and values and poor knowledge that contribute to women’s level of participation in screening for cervical cancer and have a significant impact on the women’s decision to take preventive action against cancer of the cervix (Abdullah et al., 2013; Chang, et al., 2013; Lee, et al., 2007; McFarland, 2009; Wong, et al., 2009). One of the most common challenges in cervical cancer prevention programs in developing countries is, increasing women’s awareness (Erbil et al., 2010; Wellensiek et al., 2002). Generally, reports from many developing countries indicated that women had inadequate knowledge of causes, risks and prevention of cervical cancer (Erbil et al., 2010; Wellensiek et al., 2002). According to the results of these studies, the rate of women applying Pap smear does not reach to the aimed level and the reasons for this are socio-demographic characteristics, attitude to a gynecologic examination and the awareness of the women of cervical cancer as well as the Pap smear test.

In spite, that the UAE has a population-based cervical screening program offering Pap-smear testing every three years for women, a concerted understanding of the knowledge, attitude, practice and patient-preferences about Pap-smear testing is lacking. Thus, the purpose of the present study is to explore these critical factors that will help to overcome potential barriers toward the successful deployment of the population-based cervical screening program in the UAE.

Materials and Methods

Study Design/Cross-sectional survey/Study Procedure

Participants for the study were recruited from various places such as the shopping malls, areas of work and other social centers using convenience sampling. The participants living in UAE, willing to provide a written informed consent were selected for the study. The participants were assured of the confidentiality of the information provided and protection of their rights to privacy, mandated by the research ethics guidelines of the human research ethics committees. The inclusion criteria mandated participants to be married women, between 18-64 years of age, having fair cognitive skills, ability to read and understand in English or Arabic (e.g. the local language). Both, UAE citizens (nationals) and expatriates from the seven Emirates: Abu Dhabi, Dubai, Sharjah, Ajman, Umm Al Quwain, Ras Al Khaimah and Fujairah were included in the study. Participants that were sick with other diseases, had inadequate mental health and were unable to meet any of the above criteria were excluded from the study.

Survey Design (Evaluation tools)

Surveys were conducted from September 2016 to March 2017. A structured questionnaire was designed and developed by a multidisciplinary team and through a review of the literature from relevant studies in (Jia et al., 2013; Jiangli Di et al., 2015; Yanikkerem et al., 2013). The evaluation tool was then pre-tested among 20 women to assess ease of understanding and time required for completion. Bilingual questionnaire in Arabic and English is represented in APPX I. The survey consisted of five functional domains: socio-demographic characteristics, knowledge, attitude, practice and patient-preferences related questions. The demographic data included age, nationality, residence location, marital status, number of marriages, age at first marriage, number of pregnancies, number of children, contraception use and miscarriages or voluntary terminations of pregnancy, Educational level, working status, and monthly income were included as items based on recommendations of an earlier study (Abdulrahman et al., 2016; Sreedevi et al., 2015; Yanikkerem et al., 2013). Questionnaires were administered during face-to-face interviews conducted in Arabic or English by physician researchers.

Data analysis and statistics

All collected data were entered into SPSS version 20 (IBM Corp., Released 2011, Armonk, NY, US) for statistical analysis. Descriptive statistics were computed for the socio-demographic variables. The overall responses to each item of the survey was recorded as percentage of the total. The percentage differences in the total responses were determined using the Chi-square test and statistical significance recorded for non-parametric data. For all tests, alpha (α) was set at 0.05. The overall responses for each of the (except the patent preference) domains: knowledge, attitude and practice, computed as percentage of total response, was further categorized in to low (0-33.3%), limited (33.4-66.6%) and high (66.7-100%), respectively.

Ethics statement

The study was approved by the institutional review boards of Dubai Health Authority, Dubai. Participants were not compensated. All participants gave written informed consent before participation. Aggregate reporting of data assured to enhance confidentiality and accurate reporting by the respondents. Anonymity of participation was also guaranteed by return of completed survey constructs to an administrator; independent and blinded to the study hypothesis. A code linking respondents to their surveys was kept isolated from the investigators.

Results

Majority of our respondents were between 30-39 years (48.5%), UAE national (430, 72%), had college or higher dg=degree certificate (361, 60%), married (580, 97%), and did not use contraception (355, 60%). Table 1 shows brief of demographic information of the participants.

Table 1.

Descriptive Demographic Characteristics of Participants (n = 599)

Variable	Number of cases	Percent of cases
Age (Years)
<29	156	26
30-39	291	48
40-49	119	20
≥50	34	6
Nationality
UAE	430	72
Non-UAE	170	28
Emirates Residing in
Abu Dhabi	23	4
Dubai	317	53
Sharjah	159	26
Ajman	52	9
Umm Al Quwain	6	1
Fujairah	19	3
Ras Al Khaimah	24	4
Education level
Illiterate	27	5
Primary and second ary school.	28	5
High school	182	30
College and higher degrees	361	60
Marital status
Married	580	97
Divorced / Widowed	19	3
Number of marriages
1	552	92
≥2	45	8
Age at first marriage, years
less than 20	160	27
20-25	311	52
≥25	125	21
Number of pregnancies
None	48	8
1-5	455	76
≥6	94	16
Number of children
None	83	14
1	87	14.5
2	135	22.5
3	107	18
≥4	185	31
Contraception
Do not use	355	60
Hormonal contraceptives	66	11
Coitus interruptus (interruption of intercourse/condom)	112	19
Uterine device /ligation	60	10
Working status
Employee	370	62
Student	25	4
Retired	9	1.5
Housewife	196	32.5
Monthly income, AED
Less than 20,000	300	50.5
20,000 - 40,000	254	43.5
More than 40,000	29	5
Miscarriages or voluntary terminations of pregnancy
0	350	60
1	145	25
2	66	11
≥3	26	4

It was encouraging that more than 85% of the total woman participants surveyed for the study were knowledgeable about the Pap smear test (512/599, 85%), and identified that the test was conducted using a vaginal swab (516/581, 89%) (p<0.001, Table 2), without anesthesia (463/599, 77%) and, that it was important for all women to undergo the test (456/499, 76%). The purpose of undergoing the pap smear test was clear to the women (346/599, 58%) and the majority were recommended to undergo the test by their gynecologist or a family physician (420/599, 70%). Yet, the understanding of the women to undergo the pap smear test every three years provided they obtained an initial negative/normal Pap smear result was poor (97/599, 14.8%). Overall, the attitude of the women towards the Pap smear test to detect cervical cancer early was positive (Table 2). Almost, three quarter of the total women surveyed for the study expressed their intention to undergo Pap smear test to prevent cervical cancer (494/599, 82%, p<0.001), regularly (466/599, 78%) (Table 2). The participants were further willing to be undergo the Pap smear screening at a nearby facility if it becomes available (458/599, 77%) and, also expressed that undergoing a Pap smear test gave them a sense of control (464/599,71%). In terms of practice, almost 50% of the women participants had undergone the Pap smear test and, one-third of them had underwent the procedure in the past five years (32%, Table 2). Women wanting to know more about the test was almost 80%, and was encouraging for the national screening program.

Table 2.

Assessing the Knowledge, Attitude and Practice of Women on PAP Smear in UAE (n=599). *p < 0.05, significance determined using Montecarlo 2 tailed significance at 95% CI.

Survey Items and Responses	n	(%)	P Value
Have you heard about Pap smear test?			<0.001*
Yes	512	85
No	87	15
How did you know about Pap smear test?			<0.001*
Gynecologist/Family Physician	382	64
Friend	72	12
Media	46	8
Health publication	99	17
What is the aim of doing Pap Smear test?			<0.001*
Detect Cervical Cancer changes	346	58
Discover Other cancers	67	11
Treat Vaginal Inflammation	78	13
Don’t know	108	18
Every Woman must take the Pap Smear test?			<0.001*
Yes	456	76
No	143	24
If the test result of Pap smear is normal, then the test should be repeated every?			<0.001*
One Year	196	33
Two Year	82	14
Three Years	97	16
Four Years	24	4
Dont know	198	33
Pap smear test is be done by?			<0.001*
X-Ray	8	1
Vaginal Swab	516	89
Ultrasound	15	3
All of the above	42	7
Pap smear test should be done under anesthesia?			<0.001*
Yes	32	5
No	463	77
Uncertain	104	17
Do you believe that you could have pre-cancer lesions?			<0.001*
Yes	129	22
No	264	44
Uncertain	206	34
Is the treatment of cervical cancer worth going through?			<0.001*
Yes	494	82
No	18	3
Uncertain	87	15
Does having a regular Pap Smear test give you a sense of control?			<0.001*
Yes	464	77
No	28	5
Uncertain	107	18
Is it valuable to have Pap Smear regularly?			<0.001*
Yes	466	78
No	39	7
Uncertain	94	16
In the case of availability of pap smear screening in a health center near you, are you going to do a pap smear?			<0.001*
Yes	458	77
No	43	7
Uncertain	97	16
Do you feel Pap Smear test is painful & with no benefit?			<0.001*
Yes	31	5
No	370	62
Uncertain	198	33
Have you had a Pap smear test?			0.03*
Yes	325	54
Uncertain	274	46
How many times did you have pap smear test in the past 5 years?			<0.001*
one test	274	51
2 tests	164	31
>3 tests	98	18
If you did not do a smear test, what were the reasons for not doing it?			0.76
Not aware	84	29
Painful Procedure	27	9
Fear of Infection	9	3
Embarrassment	31	11
No symptoms	80	27
Afraid of Cancer discovery	63	21
If you did pap smear, what were the reasons for doing it?			0.83
Early detection of cancer	230	60
Vaginal bleeding	21	5
Newly married	6	2
Recommended by the doctor	102	26
Reading it somewhere	20	5
Had done it before, repeating it	7	2
Where would you prefer to do the pap smear test?			<0.001*
Primary Care	90	15
Gynecologists	330	55
Private center	36	6
No preference	143	24
Whom do you prefer to do the pap smear test?			<0.001*
Primary Care	39	7
Gynecologists	530	91
Private center	11	2
Nurse	5	1
Would you like to more about the pap smear test?			<0.001*
Yes	522	88
No	68	12
Who is most suitable to raise awareness about pap smear test?
Primary Care	422	72
Gynecologists	51	9	<0.001*
Media	50	9
Community Campaign/ Schools	61	10

Almost all of the women participants preferred to undergo Pap smear test by a gynecologist (530/599, 91%) as compared to a primary healthcare physician. The primary reason for women not undergoing the Pap smear test was either due to no symptoms or being not aware about the test (less than 24% did not undergo the test). Pain, embarrassment, fear of infection and fear of cancer detection, were not significant enough (p<0.76) reasons to deter women away from the test. Early detection of cervical cancer (230, 60%) and physician recommendation (102, 26%) aided in women wanting to do the Pap smear test. Less than 10% of the women participants preferred “Pap smear awareness campaigns” to be launched from various portals such as the media, community and the schools. Pap smear awareness from the primary healthcare centers was preferred by the majority (422/599, 72%) of the women.

Assessment of adequacy of Knowledge, Attitudes, and practice related to the Pap test in relation to the demographic and gynecological characteristics of women

There was a significant difference of knowledge between employed and unemployed women, with employed women having higher rate of adequate knowledge (188/370, 51%, p=0.005). The practice of performing Pap smear was significantly different by age group with women aging 30-39 years old having the best practice (163/291, 56%, p=0.001). Furthermore, having higher income (21/29, 72%, p=0.027) and more miscarriages were associated with better practice of Pap smear (19/26, 73%, p=0.010) (Table 3).

Table 3.

Assessment of Adequacy of Knowledge, Attitudes, and Practice Related to the Pap Test in Relation to the Demographic and Gynecological Characteristics of Women in UAE (n=599). *p < 0.05, significance determined using Montecarlo 2 tailed significance at 95% CI.

Variable		Adequate knowledge			Appropriate attitude			Adequate test practice
	Total	n	%	p	n	%	p	n	%	p
Age (years)
<29	156	47	30	0.082	58	37	0.432	62	40	0.001*
30-39	291	139	48		132	45		163	56
40-49	119	62	52		57	48		76	64
≥50	34	19	56		16	47		24	71
Nationality
UAE	430	190	44	0.681	187	43	0.815	238	55	0.178
Non-UAE	170	81	48		75	44		87	51
Emirates Residing
Abu Dhabi	23	8	35	0.194	15	65	0.845	18	78	0.889
Dubai	317	184	58		132	42		161	51
Sharjah	159	72	45		68	43		92	58
Ajman	52	31	60		25	48		26	50
Umm Al Quwain	6	17	283		10	167		10	167
Fujairah	19	3	16		4	21		5	26
Ras Al Khaimah	24	12	50		8	33		12	50
Education level
Illiterate	27	10	37	0.182	13	48	0.985	14	52	0.121
Primary /secondary school	28	13	46		8	29		15	54
High school	182	59	32		80	44		104	57
College and higher degrees	361	184	51		160	44		191	53
Marital status
Married	580	259	45	0.514	253	44	0.821	315	54	0.573
Divorced / Widowed	19	8	42		10	53		11	58
Number of marriages
1	552	251	45	0.642	238	43	0.51	299	54	0.957
≥2	45	15	33		24	53		26	58
Age at first marriage, years
less than 20	160	64	40	0.842	68	43	0.43	86	54	0.257
20-25	311	144	46		136	44		167	54
≥25	125	59	47		571	457		71	57
Number of pregnancies
None	48	17	35	0.364	21	44	0.8	22	46	0.71
1-5	455	204	45		192	42		239	53
≥6	94	46	49		49	52		64	68
Number of children
None	83	31	37	0.921	34	41	0.285	34	41	0.198
1	87	36	41		37	43		43	49
2	135	60	44		53	39		76	56
3	107	43	40		40	37		57	53
≥4	185	95	51		98	53		115	62
Contraception
Do not use	355	141	40	0.897	148	42	0.173	183	52	0.583
Hormonal contraceptives	66	33	50		32	48		44	67
Coitus interruptus	112	62	55		56	50		63	56
Working status
Employee	370	188	51	0.005*	172	46	0.368	212	57	0.079
Student	25	9	36		6	24		9	36
Retired	9	4	44		5	56		6	67
Housewife	196	66	34		80	41		99	51
Monthly income, AED
Less than 20,000	300	116	39	0.204	122	41	0.158	142	47	0.027*
20,000 - 40,000	254	127	50		110	43		151	59
More than 40,000	29	21	72		21	72		21	72
Miscarriages or voluntary terminations of pregnancy
0	350	165	47	0.114	155	44	0.073	183	52	0.010*
1	145	55	38		56	39		77	53
2	66	33	50		36	55		46	70
≥3	26	12	46		16	62		19	73

Comparison between the knowledge, attitude and practice domains

Overall, the women in the UAE were limited (66.3±22.2) in their knowledge about the Pap smear test (Table 4). Their understanding to undergo the Pap smear test every three years provided they obtained an initial negative/normal Pap smear result was abysmal. In spite of the positive attitude of the women towards the Pap smear test, almost 80% of the women surveyed were unaware of precancerous lesions (Table 4). Although, 50% of the women surveyed did undergo the Pap smear test, one-third of them did not establish a practice of undergoing regular tests (Table 4).

Table 4.

Knowledge, Attitudes, and Practice Towards and Reasons for Undergoing the Pap Test in UAE (n=599).

Domain	Survey Items	Expected Responses	Number (n)
			Percent (%)
Knowledge	If the test result of Pap smear is normal, then the test should be repeated every?	Three	97 (15)	Mean± SD 66.3±22 Outcome Limited
Knowledge	What is the aim of doing Pap Smear test?	Detect Cervical Cancer Changes	346 (53)
Knowledge	How did you know about Pap smear test?	Gynecologist/	382 (58)
		Family Physician
Knowledge	Every Woman must take the Pap Smear test?	Yes	456 (70)
Knowledge	Pap smear test should be done under anesthesia.	No	463 (71)
Knowledge	Have you heard about Pap smear test?	Yes	512 (78)
Knowledge	Pap smear test is be done by?	Vaginal Swab	516 (79)
Attitude	Do you believe that you could have pre-cancer lesions?	Yes	129 (20)	Mean± SD 60.5±21 Outcome Limited
Attitude	Do you feel Pap Smear test is painful & with no benefit?	No	370 (56)
Attitude	In the case of availability of pap smear screening in a health center near you, are you going to do a pap smear?	Yes	458 (70)
Attitude	Does have a regular Pap Smear test give you a sense of control?	Yes	464 (71)
Attitude	Is it valuable to have Pap Smear regularly?	Yes	466 (71)
Attitude	Is the treatment of cervical cancer worth going through?	Yes	494 (75)
Practice	Have you had a Pap smear test?	Yes	325 (50)	Mean± SD 53.7± 24 Outcome Limited
Practice	How many times did you have pap smear test in the past 5 years?	>3	161 (32)
Practice	Would you like to know more about the pap smear test?	Yes	522 (80)

The knowledge levels of the women in the UAE was significantly higher (66.3±22.2,), when compared to their attitude (60.5±20.9, p= 0.03, 95% CI {0.22-11.3}, Chi-square 4.38) and, practice (53.7 24.1, p= 0.001, 95% CI {6.9-18.1}, Chi-square 19.7) (Campbell, 2007; Small et al., 2017).

Discussion

Cervical cancer is a slow-developing cancer of the cervix uteri of the female genital tract. Almost all cases are strongly associated with oncogenic infection with the Human papillomavirus (HPV) (Small et al., 2017). Cervical cancer contributes to 7.5% of female mortality and almost over 250,000 deaths worldwide (Small et al., 2017). It has been proposed that by the year 2020, almost 0.7 million women could develop cervical cancer unless screening and community interventions are implemented for early detection and improved women’s health outcomes (Ilter et al., 2010). Cervical cancer has been reported to be less common in Muslim Countries compared to other countries in the world (Forman et al., 2012, Kelly, G. 2014). Given the paucity of regional incidence and prevalence studies, it might be difficult to pin-point specific reasons for the reported low incidence in Muslim countries. Under-reporting, and social reservations towards screening stemming from cultural rather than religious beliefs and values could be significant factors for the observed low incidence, both in the UAE and the Muslim countries (Khan and Woolhead, 2015). Although cervical cancer is largely preventable, the symptoms remain elusive until the cancer advances. Therefore, it is important that healthy women be screened for early detection of asymptomatic precancerous lesions (Small et al., 2017). Pap smear test with a sensitivity range up to 70% is the tool of choice to detect early stages of the disease (El-Hammasi et al., 2009). Reports have indicated that countries that lack a national cervical screening program, record a higher prevalence of cervical cancer compared to countries with national screening program (El Banna et al., 2014). Screening acceptance has been found to be strongly correlated with the religion and culture (Wong et al., 2013). Fatalistic beliefs guided Muslim women in Malaysia leading them to refuse cervical cancer screening and early detection (Wong et al., 2013). Immigrants in the United States, especially the Muslim women expressed apathy towards cervical cancer screening (Padelaet al., 2014), while another group of American Arab women expressed that their faith and beliefs detached them from the fear of cancer diagnosis (Padela et al., 2014; Salman, 2012). Studies from Qatar and Saudi have also suggested the need for generating measures to educate women in pursuing cervical cancer screening programs (Al-Meer et al., 2011; Sait, 2009).

In the UAE, cervical cancer screening, although covered by the national insurance providers, is performed opportunistically on women who visit health facilities. The lower screening rates (< 20%) have generated a public health alarm to scale up the Pap smear test screening program (Aswadet al., 2013). Results indicate that more than 86% of the total women participants surveyed for the present study were knowledgeable about the Pap smear test in the UAE. They were also well-informed that the test was conducted using a vaginal swab (89%) and without anesthesia (77%) and, that it was important for all women to undergo the test (82%). Interestingly, given that the Pap smear test is performed on women who visit the healthcare facilities, only 50% of the women surveyed had undergone the test. Comparing with an earlier report from Sharjah, UAE, where a vast majority of women had not even heard about the Pap smear test (Bakheit and Haroon, 2004), our results are encouraging. This does not discount the requirement to have a structured mandatory screening program for cervical cancer in the country. In spite that more than 50% of the women were recommended by their gynecologists to undergo a Pap smear test, incentives for the gynecologists to motivate women will prove to be beneficial towards limiting the incidence of cervical cancer in the UAE. It is presumed that having women physicians as “crusaders of the cause” will motivate more women to undergo the test, given the cultural sensitivity of the population. On the positive side, 77% of women surveyed in our study expressed their intention to undergo the test, and more so, if the service was available at a nearby facility. Unlike other studies (Salman, 2012; Bakheit and Haroon, 2004) pain, embarrassment, fear of infection and fear of cancer detection, were not significant enough (p<0.76) reasons to deter women away from the test in our study. Employed women had better knowledge on pap smear while women with higher family income had more adequate practice towards testing. This was in accordance with other reports from Brazil (Fernandes et al., 2009), Argentine (Gamarra et al., 2005), India (Bansal et al., 2015); and Malaysia (Abdullah et al., 2011).

The UAE in the past forty-five years has transformed from a traditional to a modern healthcare provider. The results from our study indicate the crucial need to have a structured cervical cancer screening program, given the fact that the women of the UAE are inclined both in terms of knowledge and attitude to adapt to cervical cancer prevention programs. Additionally, this study is the first study of the region, which has addressed the preferences of the women in relation to cervical cancer screening program. It is anticipated that the results of this study can be applied to similar cultures and ethnic background population in the countries of the Middle East.

In conclusion, a well-designed health education programme on cervical cancer and benefits of screening would increase the awareness among women in UAE. On that issue, a multimedia approach utilizing pictorials, audio-visual and personal communication on cervical cancer could yield beneficial results. One more important point is the fact that better communication with health professionals and improvement of access to health care services should increase the rate of cervical cancer screening.

Limitations

This study has several limitations. It only focused on the knowledge of the women in some common places in UAE. It may not be generalized to all target populations, especially the target women who didn’t attend these common places might have different knowledge and attitude on this regards. Therefore, the results of this study should be interpreted with caution. This study used a cross-sectional design; thus, it only speculated on the causal relationship between the variables. It used convenience sampling, so the results might be unrepresentative of the population being studied. However, despite these limitations, the results of this study provide a basis for further planning future in-depth research prior to developing educational materials and planning training-based interventions for the implementation of the Pap smear screening in UAE.

Funding

The authors have not received any funding or benefits from industry or elsewhere to conduct this study.

Conflicts of interest

There are no conflicts of interest.