Factors Related to Poor Practice of Pap Smear Screening among Teachers in Malaysia

RESEARCH COMMUNICATION Factors Related to Poor Practice of Pap Smear Screening among Secondary School Teachers in Malaysia
Fauziah Abdullah1,2*, Norlaili Abdul Aziz3, Tin Tin Su1
Abstract
Introduction: The Pap smear test has been regarded as a promising cervical screening tool since 1940s. Yet its importance has been overlooked by beneficiaries in Malaysia. This underlines the need to identify the prevalence of Pap smear practice and influencing factors towards the practice among educated working women. Methods: A survey was conducted with 403 female teachers from 40 public secondary schools in Malaysia selected by cluster random sampling. Data were collected from January to March 2010 using a self-administered questionnaire. Multivariate logistic regression was performed to identify the factors related to the Pap smear practice. Results: The rate for participants who ever had Pap test was only 38% and poor practice of was significantly higher among: those with aged less than 35 years; those practicing hormonal contraceptive method; and individuals perceiving barriers to the Pap smear screening test. In contrast, the findings were significantly lower in women with longer duration of teaching service; higher income groups; ever pregnant; having chronic diseases; health insurance coverage; and who had perceived benefit of Pap smear screening. Conclusion: Barriers towards practicing Pap smear exist even among educated career women. Tailor-made health promotion and education on cervical cancer and the benefit of Pap smear screening are essential to change the behavior of the study population. Keywords: Pap smear practice - related factors - cervical cancer prevention - Malaysia Asian Pacific J Cancer Prev, 12, 1347-1352

Introduction
Cervical cancer has emerged as a major global public health problem. It accounted as one of top 10 common cancers worldwide. Among women, it ranked as the third commonest cancer in developed countries and as the second in developing countries (Parkin et al., 2002; Boyle and Levin, 2008). In Malaysia, cervical cancer remains as one of top five commonest cancers among women. It is still considered the second commonest cancer in women aged 15-49 years old that categorized as the risk group (Lim et al., 2002, Chye and Yahaya, 2003, Omar et al., 2006, Chye et al., 2008). The incidence rate of 12.2 per 100,000 in 2006 was higher compared to other countries such as Australia, New South Wales and USA (Omar et al., 2006). Nearly 80% of cervical cancer patients still presented at advanced stages (Ministry of Health Malaysia, 2003, Othman et al., 2009). Generally developing countries have lower Pap smear coverage (19%) as compared to developed countries (63%) (Gakidou et al., 2008). In Malaysia over the last 10 years, Pap smear coverage within three years has declined from 74.5% in 1996 to 59.7% in 2006 (Institute for Public Health (IPH), 1999, Institute for Public Health (IPH), 2008). Moreover, educated and employed women who supposed to be the ideal women group are also experienced with similar trend of poor Pap smear practice
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(Shamsuddin and Zailiza, 2001; Chee et al., 2003; Wai et al., 2008). This introduced worries since working women population is rising where within 51 years (1957-2008) women’s participation rate in labour force has increased by 15.3% (Department of Statistics, Malaysia, 2009). Worldwide, most of the studies on Pap smear screening practice were conducted among women as in general and in particular certain groups of women like health workers, academician at college or university level, factory workers, and female students at college or university level (Rosvold et al., 2001; Shamsuddin and Zailiza, 2001; Chee et al., 2003; Aniebue and Aniebue, 2010). Generally, various factors have been discovered in affecting the behaviour of practicing Pap smear screening test in women such as sociodemographic, socioeconomic, reproductive history, lifestyle or risk behaviour, attitudes, beliefs, sociocultural, information, knowledge, and provided services (Eaker et al., 2001b; Bessler et al., 2007; Cabeza et al., 2007; Abdullah and Su, 2010). Among the identified barrier factors found in educated and/or working women were embarrassment, fear, time constraints, knowledge deficits, and cost (Boonpongmanee and Jittanoon, 2007; Abdullah and Su, 2010). Very few studies have been performed on female school teachers. Till now, only four studies were discovered on the practice of Pap smear screening test in female school teachers, namely two Taiwan studies by

Centre for Population Health (CePH), Department of Social & Preventive Medicine,Faculty of Medicine, University of Malaya, Ministry of Health, Malaysia, 3Cyberjaya University College of Medical Sciences, Malaysia *For correspondence: abdullah_ fauziah@yahoo.com Asian Pacific Journal of Cancer Prevention, Vol 12, 2011

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Yang (1991) and Cheng (1994); an Italian study by Pavia et al (1999); and a Middle East study by Bakheit and Haroon (2004). Though, these studies only addressed as lightly by exploring the knowledge, attitude and practice of cervical cancer screening and could not address the factors related to the practice of Pap smear. This information is essential because female school teachers are considered as a prime group in educating and disseminating reproductive health topic to students and public. In order to fulfill this information gap, we conducted the study among secondary school teachers in Malaysia. The purpose of our study was to identify the prevalence of Pap smear practice and influencing factors towards poor practice of Pap smear.

Fauziah Abdullah et al

Table 1. Factors for Poor Practice of Pap Smear Screening (n = 403)
Variables Pap smear practice Ever Never χ2 (n=153) (n=250) test p-value

Materials and Methods
This was a baseline survey, sampled from cluster randomized trial study of female teachers in selected 40 secondary schools in Kuala Lumpur which is the capital city of Malaysia. The reasons of selecting this as setting because of low prevalence of Pap smear uptake noted among production workers, tertiary educated women and in the state of Kuala Lumpur (Shamsuddin and Zailiza, 2001, Institute for Public Health (IPH), 2008, Wai et al., 2008). In addition, schools are rich with female employees who are at reproductive age group and with higher educational level. There are 84 National Secondary Schools in Kuala Lumpur which divided into four zones with average 20 schools at each zone. Cluster random sampling method was used in selecting 10 schools from each zone. Female secondary school teachers from selected schools who fulfilled inclusion criteria and consented were involved in the study. A total of 403 participants from 40 schools were included in the study. The respond rate was considered low. Though, there was no significant difference in terms of background characteristics between respondents and non-respondents. Sample size that required was 320 participants included 20% of nonrespondents which was calculated by Power and Sample Size Program software. Data collection was done from January to March 2010. Ethics approval was obtained from University Malaya Medical Centre (UMMC) Ethics Committee and Ministry of Education of Malaysia. A written informed consent was taken from all the respondents. Self-administered questionnaire was applied as a study instrument which focused on five areas as predictors of the Pap smear uptake: (i) demographic and socioeconomic; (ii) reproductive history; (iii) lifestyle or risk behaviour; (iv) attitudes and beliefs factors that constructed based on the Health Belief Model; and (v) stages of cervical screening behaviour change that constructed based on the Transtheoretical Model. The questionnaire was in bilingual form, namely Malay, the national language and English language. It had been pre-tested for reliability, validity, and cultural appropriateness among 33 female teachers who were volunteered from one National Secondary School in Kuala Lumpur that was not involved in this study. The pre-test was conducted in August 2009.

Demographic and Socioeconomic Age: ≤ 35 years 32 (15.8) 171 (84.2) 85.610