Women of Child Bearing Age Knowledge, Attitudes and Practice on Pap Smear Screening in Okongo Health District on Ohangwena Region, Namibia

Women of Child Bearing Age Knowledge, Attitudes and Practice on Pap Smear Screening in Okongo Health District on Ohangwena Region, Namibia

J Hainana¹, J Sheehama², P Shingandji³

¹Okongo District Hospital, Ministry of Health and Social Services, Namibia

²School of Medicine, University of Namibia, Namibia

³School of Nursing and Public Health, University of Namibia, Namibia

DOI: https://doi.org/10.51244/IJRSI.2025.121500070P

Received: 15 April 2025; Accepted: 19 April 2025; Published: 27 May 2025

ABSTRACT

The Pap smear screening is a technique that is used to gather cells from the cervix for cervical cytology testing which recognize the advancement of Human Papilloma Virus (HPV) that cause cervical cancer. The study assessed knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district of Ohangwena region. A quantitative analytical cross-sectional study was adopted to collect data from 238 participants aged 16-49 years in Okongo district as from the period of April to September 2023 using structured questionnaires that were entered in Microsoft excel and exported into Epi Info version 7.2.6 for analysis.

Among participants, the majority of respondents (56%), were from the age group of 25-34 years, single (68.9 %) and residing in rural areas (81.9 %). 91.6 % of respondents had good knowledge towards Pap smear screening mainly informed by health care workers. A mixed attitude towards Pap smear screening was observed in the study with a larger proportion of respondents scored unfavorable score (56.7%). Practice towards Pap smear was encouraging with 64.3 % of respondents previously being screened for Pap smear. The study showed statistically significant associations between educational level and both awareness of Pap smear screening (P value 0.04) and practice (P value 0.02) as well as the significant association between attitudes and screening practices (P value 0.04). Health education and accessibility of screening services will be essential in achieving higher participation rates and ultimately reducing the incidence of cervical cancer.

Keywords: Knowledge, Attitudes, Practice, Women of Childbearing age, Pap smear screening

INTRODUCTION AND BACKGROUND OF THE STUDY

Introduction and Background

Papanicolau (Pap) smear or Pap smear screening is defined as a technique used to gather cells from the cervix for cervical cytology testing. Whereas cells are collected from the surface of uterine cervix and the cervical canal using a plastic spatula or a brush (1). These cells are either smeared on a glass slide or immersed into a compartment with preservative solution and afterward shipped off to a cytological laboratory for investigation by a pathologist for cancer or pre-cancerous change by looking at cells under the microscopes(1). Pap smear test is performed every year to women who are at risk of developing cervical cancer (1). Pap smear screening is started at age of 21 of which is done within 3 years after a woman engage into sexual contact and proceeds until 70 years in developed countries such as USA (1). Other countries, such as Britain, screening is started at the age of 25, then every 3 years until 49 and from there every 5 years until 65 years (1). However, in developing countries screening is incompatible, possibly started during the 30s and afterward directed at regular intervals of 5 years and sometimes only one-time screening is performed between 35 and 40 years old through outreach services by going in the community and provide screening services to the population that might not have access to the services (1).

Pap smear screening is performed to recognize the advancement of Human Papilloma Virus (HPV) actuated cervical cancer and other abnormalities in the female genital tract (2). In most instances, cervical cancer is caused by type 16 and 18 of HPV which is found in about 70% of all reported cervical cancer cases and it is sexually transmitted through sexual contact with an infected partner (3).

Factors that influence women infected with HPV to develop cervical cancer include early sexual contact, having children at early age, multiple sexual partners, delivery of more than 5 births, Human immunodeficiency virus (HIV) infection and other Sexually Transmitted Infections (STIs), Immunosuppression due to HIV or other diseases (1). There is also potential factor that include long term use of contraceptives and smoking cigarettes (1).

Cervical cancer is one of the most preventable and treatable forms of cancer if detected early and it can be managed effectively (4).Strong evidence shows that the progression of cervical cancer into its later stages can be prevented through screening and treatment of premalignant lesions (4).Thus, the incidence of cervical cancer has been controlled due to effective screening programs, especially the systematic use of the Pap smear test for identifying premalignant changes in the cervix (4).

Several factors such as educational status, financial capability, location, presence of health care facilities determine the stage at which patients with cancer present in the health facility. However, a common denominator of these factors is the level of awareness and attitude patients have about the disease (4). There is an increased chance of presenting early for treatment if patients have awareness about the disease (4).Therefore, this study aimed to determine knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district of Ohangwena region.

Statement of the Problem

Despite Health care workers providing information to women during Antenatal care (ANC), Postnatal care (PNC) as well as to those who come for family planning (FP) on the need to have a regular Pap smear screening, The uptake of Pap smear screening remains low and women are mostly only screened when referred by healthcare workers (3).

Even though the latest National Demographic Health Survey (NDHS) conducted in Namibia in 2011 reported that women who are aged 21 years old and above as well as those that are sexually active should have annual Pap smear test, results indicated that only 66 percent of women aged 15-49 are aware of pap smear with only 25 percent performed a pap smear test (2).Namibian women aged from 15 years and above who are at risk of acquiring cervical cancer were estimated to be around 813 157 in 2018 with 236 diagnosed and 135 deaths per year from cervical cancer (5).These figures about cervical cancer came as a surprise due to the fact that the disease is preventable, and it can be cured (5).

Furthermore, according to a study done by The Southern Africa Litigation Centre (SALC) (3) in Namibia, it was found out that there is a varied level of knowledge in the country depending on place where it is higher in urban areas as well as amongst HIV positive women compared to rural areas and HIV negative women that have low knowledge (p.28). It was further indicated that misleading information by healthcare workers to clients on the cause of cervical cancer is of a great concern in Namibia (3).

It has been observed in Okongo district that only few women take advantage of Pap smear screening service that is available. According to the latest Census record which was conducted in 2011, There were 12 500 women of childbearing age in Okongo Constituency where Okongo health district is falling under (2).Furthermore, records from District Health Information System (DHIS) of the MOHSS in Okongo district showed that during financial year 2020/2021 only 325 Women of childbearing age were screened for Pap smear out of 2632 Women who attended FP revisit and 1145 who delivered (6).Given the situation about low uptake of Pap smear screening, it is reasonable to presume that, there are missed opportunities and obstacles to Pap smear screening which are of a public concern (7).

When Pap smear test is done every year, it helps to detect cervical cancer early and for it to be cured (2).Moreover, women who are not tested for Pap smear yearly especially those at risk of developing HPV are at high risk as by the time they come for testing sometimes the cervical cancer had developed already into late stages and dispersed to other parts of the body (2).This can result into high morbidity and mortality of cervical cancer as well as other diseases related to cervical cancer such as anaemia caused by suppression of bone marrow due to chemotherapy (2).Developing cervical cancer can result into disabilities also for example when a woman operated for hysterectomy to remove uterus and prevent further spreading of cancer which results in a woman unable to bear children and this cause psychological problem. Cervical cancer can be prevented by addressing prevention services on early stages such as providing information on cause and prevention of cervical cancer, HPV inoculation on children, screening methods of cervical cancer and follow-up of cervical cancer screenings (3).

Even though cervical cancer can be prevented, it is yet the second most common cancer among women and almost half a million women globally are diagnosed with cervical cancer (8).Furthermore, due to lack of effective cervical screening intended to detect and treat pre-cancerous conditions, most patients in developing countries are diagnosed in the late stages of cancer because of delayed early detection and this results in poor prognosis of the disease (8).Moreover, cervical screening identifies pre-cancerous lesions, and their removals prevent the cancer to develop into advanced stages (8).

Regardless of whether intensified screening programs are planned, the achievement of these projects will rely upon the awareness and attitude of the women who get those (8).Therefore, it is against this background that the study will be carried out to determine the knowledge, attitudes and practice of women of child bearing age on pap smear screening in Okongo health district in order to assist women to be aware of cancer screening methods and regular pap smear screening, which can make them to adhere to attending cervical screening regularly which consequently lessen the risk of developing advanced cervical cancer (8).

Purpose of the Study

The purpose of this study is to determine the knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district to which it is hoped to strengthen the Pap smear program and increase it is uptake.

Objectives of the Study

1. To determine the level of knowledge of women of childbearing age on Pap smear screening in Okongo health district.
2. To assess the attitudes of women of childbearing age toward taking up Pap smear screening in Okongo health district.
3. To determine the practice of women of childbearing age with regard to Pap smear screening up taking in Okongo health district.

Significance of the Study

The information to be obtained from this study will be used to generate additional knowledge on knowledge, attitudes and practice of women of reproductive age and draw recommendations to Okongo district health authority and to the Ministry of Health and Social Services (MoHSS) at large on best practices to raise public awareness on Pap smear screening and the prevention of cervical cancer among rural communities in Namibia. Furthermore, this study will help to inform health policy makers, Health care workers and women about Pap smear as a cervical cancer screening which can lead to the reduction of cervical cancer cases in Namibia.

RESEARCH METHODOLOGY

Quantitative analytical cross-sectional method of study was used in the study to establish the knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district of Ohangwena region.

In this study the design is determined by the research questions and its objectives whereby, a  quantitative analytical cross-sectional study will be used in the study  to determine the knowledge, attitudes and practice of women of bearing age on pap smear screening in Okongo health district.It has been observed that there is a big contrast in a number of women who come to the health facilities to be screened for Pap smear in comparison to the population of women of child bearing age and this motivated the researcher to ask what may be the contributing factors to low uptake of  Pap smear screening among women of child bearing age in Okongo health district. Knowledge of women was assessed on importance of Pap smear screening and their attitude towards the procedures during the screening.

Population of the Study

Population refers to the entire group of people or subjects that possess some common characteristic that is of interest to the researcher(14).A population is selected by the researcher to participate in the research study (14).According to DHIS report of the year 2020/2021 it is indicated that, the total population of Women of childbearing age in Okongo health district was 7199.The target population for this study will comprise of women aged 16 – 49 years residing in Okongo health district who come to health facilities for Pap smear screening.

SAMPLING AND SAMPLE METHOD

A sample is a subset of the population that is selected to represent the population (14).A systematic random sampling was used in the study by taking every 3^rd participant until the required number is enough. Participants were selected based on the inclusion and exclusion criteria.

Sample Size Determination

The sample size of this study was determined by using the similar online software, which is known as Raosoft sample size calculator which was used in Malaysia to calculate the desired sample size of    Knowledge, Attitude and Practice of Pap Smear Screening among Women in Gombak District, Selangor (10).Information such as level of precision, confidence interval, and population size and response distribution will be entered to determine the sample size of the study. There were a total number of 7199 women of childbearing age during the financial year 2020/2021 in Okongo district (6).With a total population of 7199, 95 % as the confidence interval, 0.05 as the level of precision and 80 % as a response distribution, the sample size of 238 subjects is recommended by raosoft sample size calculator.

Eligibility Criteria

Inclusion criteria include women of childbearing age aged 16–49 years old residing in Okongo health district, who can read and understand either English or Oshiwambo and must be participating on a voluntary basis. Exclusion criteria include women of childbearing age who will not be consenting to participate in the study, already diagnosed with cervical cancer as well as those who are mentally ill.

Data Collection

Data collection is the precise, systematic gathering of information relevant to the research purpose (13).A structured questionnaire consists of 4 sections namely: A-Demographic information , B-Knowledge, C-Attitude and D-Practice will be used in this study.

Ethical Clearance Procedure

To protect the right of participants, permission to conduct the study was granted or obtained from the following relevant authorities:

Ethical clearance from the University of Namibia, approval from Executive Director of the Ministry of Health and Social services and official permission from the Regional and district management teams such as Ohangwena regional health Director, Okongo Senior medical officer and Okongo District Primary Healthcare Supervisor.

RESULTS OF THE STUDY

The purpose of this study was to determine the knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district of Ohangwena region.

This chapter also presents the outcomes of 238 respondents that will be presented as according to how the questions were completed in the questionnaires by the respondents. The results of this study are divided into the following 4 sections; firstly, the demographic data of respondents such as age group, educational level, number of children, marital status, religion, place of residence, occupation and contraceptive methods used. The second section will focus on describing the knowledge about Pap smear screening while the third section will describe attitudes of participants towards Pap smear screening practices and the last section describes the practice of Pap smear screening by the respondents.

Data collection and data analysis will also be presented in this chapter. This is aimed to exploring and organizing the raw data, in order to give the collected data a meaning (14).This is followed by a descriptive analysis and summary of relevant data reflecting frequency, tables, and percentages that were used. This was done to describe the demographic data of the respondents as well as to determine knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district in order to increase its uptake. This will be followed by a description of findings and finally the conclusion of this chapter.

Descriptive Data Analysis

The incidence of cervical cancer has been controlled due to effective screening programs, especially the systematic use of the Pap smear test for identifying premalignant changes in the cervix (4).Therefore, knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district are examined here. This analysis is based on data gathered from a group of 238 women of childbearing age who were receiving Pap smear screening at public health facilities in Okongo health district.

Descriptive statistic is used in the study to analyze data, whereby data collected are converted into organized, visual portrayal or image in various ways, with the goal that the information can make the readers understand the meaning of the study report.

On the other hand, knowledge, attitudes and practice of women of childbearing age on Pap smear screening in Okongo health district are examined here by determining why the utilization of Pap smear in the district is low among women of childbearing age and what are the characteristics of participants who are using the Pap smear screening. In the study, the response variable is the utilization of Pap smear screening that is done in public health facilities in Okongo health district.

Socio- Demographic Information

A total number of 238 women of childbearing age participated in this study. The mean age of study population was 30.1 ± 6.8 years, ranging from 16 to 49 years, with representation of respondents from all the age groups. The majority of respondents were from the age group of 25-34 years that counts for 132 (56%), followed by 35-49 years of age with 58 (24%). The least respondents were those in age group of 16-24 years counting for 48 (20%). The age group variation is shown on the figure 1 below.

Figure 1: Proportion of the respondents by age groups, Okongo health district (N=238)

Additional analysis, among age group of 16-24 years 48 (98%) of respondents were single women and this was the same finding among age group of 24-34 years whereby majority of respondents were also single with 99 (77%). However, among age group of 35-49 years, majority of respondent were married women with 43 (72%). Moreover, across all age groups, most of respondents were unemployed women count for 170 (71.4%). This might be due the fact that unemployed women are the one mostly visit the public health facilities, hence this study was conducted at public health facilities, unlike, employed ones who make use of private health facilities.

Figure 2: Proportion of women of childbearing age by Religious, Okongo health district (N=238)

Figure 2 above shows that the majority of respondents were from Lutheran religion background which accounts for 100 (42%), followed by Anglican and Catholic with 92 (38.7%) and 34 (14.3%) respectively while Pentecostal counts for 10 (4.2%). Moreover, among all respondents, only 2 women belonged to other regions which counts for 0.8%. This is due to fact that the Lutheran and Catholic churches are the popular and oldest religions found in Okongo health district and in Ohangwena region at large.

Figure 3: Proportion of women of childbearing age by level of education, Okongo health district(N=238)

The majority of respondents 124 (52.1%) had secondary education as illustrated in figure 3 above, and most of these women are from the age group of 24-34 years which accounts for 69 (56%). It also shows that the least of respondents had only primary education which count for 54 (22.7%) of which the highest respondents were among age group of 35-49 with 26 (48%). In this study, tertiary education was count for 56 (23.5%) across all age groups.

Table 1: Demographic information of women of childbearing age, Okongo health district (N=238)

Variables	Number (n)	Per cent	95% CI
Marital status
Single	164	68.9%	0.63-0.73
Married	72	30.3%	0.24-0.36
Other	2	0.8 %	0.00-0.02
Religious affiliation
Lutheran	100	42.0%	0.35-0.38
Anglican	92	38.7%	0.32-0.34
Catholic	34	14.3%	0.09-0.18
Pentecostal	10	4.2 %	0.01-0.06
Other	2	0.8 %	0.00-0.02
Place of residence
Urban	43	18.1	0.13-0.22
Rural	195	81.9%	0.77-0.86
Educational level
Primary	54	22.7 %	0.17-0.28
Secondary	124	52.1 %	0.45-0.58
Tertiary	56	23.5 %	0.18-0.29
Other	4	1.7 %	0.05-0.03
Employment status
Employed	62	26.1 %	0.020-0.31
Unemployed	170	71.4 %	065-0.71
Other	6	2.5 %	0.05-0.04
Contraceptive use
None	53	22.3 %	0.35-0.38
Oral pills	23	10.0 %	0.32-0.44
Injectable	69	29.0 %	0.09-0.18
Condom	56	24.0 %	0.01-0.06
IUD	8	3.4 %	0.00-0.02
Other	29	16.4 %	0.07-0.05

Table 1 above shows that most of the respondents were single which counts for 164 (68.9%), while married respondents were 72 (30.3%) Furthermore, the majority of   respondents were from rural areas which account for 195 (81.9%), while most of respondents 170 (71.4%) were unemployed. The results further showed that injectable was most common method 69 (29%) used by the respondents for contraception, of which most used by married women with 38% when compared with single which only count for 25%. However, 53 (22.3%) of respondents have indicated that they are not using any contraceptive method. Other demographic information of the respondents is presented in table 1. A 95% Confidence Intervals (CIs) above shows that if researcher were to take 100 different samples and compute a CI for each sample, approximately 95 of those intervals would contain the true population parameter. Therefore, the narrow range shows a fairly precise estimate, indicating that the data collected was likely sufficient to give a good estimate of the true proportion.

Knowledge on Pap Smear

In this study, findings show that the majority of respondents 218 (91.6%) scored good knowledge on Pap smear screening. More than half of respondents 169 (71.0%) received the information from Health care workers (HCWs), followed by social media with (18.5%). The results showed that 99.9% of respondents had knowledge on risk factors that cause development of cervical cancer. These findings are illustrated in figure 4 and table 2 below.

Figure 4: Proportion of the respondents by Source of knowledge, Okongo health district (N=238)

Table 2: Knowledge of women of childbearing age on Pap smear screening (N=238)

Variables	Number (n)	Per cent	95 % CI
Heard about pap smear
Yes	218	91.6 %	0.88-0.95
No	20	8.4 %	0.04-0.11
Source of information
Social media	44	18.5 %	0.13-0.23
Health care workers	169	71.0 %	0.65-0.75
Friends/Family	19	7.98%	0.45-0.11
Internet	07	2.9 %	0.07-0.05
Risk factors
Having multiple sexual partners	30	12.6 %	0.08-0.16
Early sexual intercourse	17	7.1 %	0.03-0.10
Family history	37	15.5 %	0.10-0.20
Long term use of contraceptives	34	14.3 %	0.10-0.19
Sexually transmitted diseases (STDs) such as HIV	39	16.4%	0.11-0.21
Having children at early age	17	7.1 %	0.03-0.10
Having more than 5 children	16	6.7 %	0.03-0.09
Smoking cigarette	03	1.3%	0.00-0.02
Other	45	18.9 %
Prevention on Cervical Cancer
Regular pap smear screening	195	56.0 %	0.33-0.46
VIA	70	20.1 %	0.23-0.35
Early detection increases survival	76	21.8 %	0.26-0.39
Other	07	2.0 %	0.07-0.05
Family history of cervical cancer
Yes	27	11.3 %	0.07-0.15
No	167	70.2 %	0.64-0.75
Do not know	44	18.5 %	0.10-0.07

Table 2 shows the knowledge summary of women of childbearing age on Pap smear screening. Majority of respondents 195 (56.0%) scored good knowledge with regard to the prevention of developing cervical cancer by going for Pap smear screening regularly. However, most of respondents 162 (68.0%) were not aware that early detection could also increases survival from cervical cancer, as evidenced by only 76 (32%) of respondents indicated these as seen in table 2. Therefore, researcher is 95% confident that the true proportion of people not aware that early detection increases survival from cervical cancer through Pap smear screening in the population is between 64% and 75%. This interval provides a reliable estimate, suggesting that health interventions need to consider this range when planning awareness campaigns.

Attitudes On Pap Smear

The results from the study show that 103 respondents scored positive attitudes toward Pap smear screening which account for 43.3%, in which majority were from the age group of 25-34 years which counts for 56% and high among the respondents who had secondary education (55.5%) compared to those with primary and tertiary education. Furthermore, 135 respondents scored negative attitudes toward Pap smear screening which accounts for 56.7%. Attitudes toward Pap smear is indicated on the table 3 below.

Table 3: Attitudes of women of childbearing age on Pap smear screening (N=238)

Moreover, most of respondents 208 (87.4%) have indicated that there is nothing that could prevent them to go for Pap smear screening and this indicated a good attitude towards Pap smear. However, lack of information was indicated as one of the hindrances that could prevent some women to go for Pap smear screening.

In addition, the confidence intervals provided in the results above indicate the range within which the true population parameter is expected to fall with a 95% level of confidence. The true proportion of respondents worried about Pap smear screening is estimated to be between 36% and 39%. While the true proportion of respondents not worried is estimated to be between 50% and 63%. The true proportion of people without any of these concerns is estimated to be between 82% and 91%. These intervals reflect the precision of the survey estimates and suggest how much the sample results might vary from the true population values.

Practice on Pap Smear Screening

The table 4 below shows that the majority of respondents 153 (64.2%) were screened for Pap smear before, with 95% confidence of true proportion between 53% and 73%. These results show that most of respondents had favorable practice and among them, more respondents were from age group of 25-34 years with 88 (58%) respectively.  Among those who were previously screened for Pap smear, majority of respondents 118 (49.6%) were initiated by healthcare workers of which half of respondents were screened between 1-5 times which accounts for 143 (60.1%). The true proportion of screenings initiated by healthcare workers is likely between 43% and 55%, with 95% confidence. However, 35.7% of respondents were never screened for Pap smear. The results showed that the majority of respondents 192 (80.7%) scored favorable scores on usefulness of information received during Pap smear screening. Among the respondents who were performed Pap smear screening, majority were performed at public health facilities which account for 60.5 % with only 16.4% of respondents had ever screened for VIA and majority of respondents 207 (86.97%) had been screened for health screening for HIV. These results are illustrated in table 4 below.

Table 4: Extend to which women of childbearing age engage on Pap smear screening practices (N=238)

Variables	Number (n)	Per cent	95 % CI
Who initiated the screening
Self-initiated	34	14.3 %	0.10-0.18
Health care workers	118	49.6 %	0.43-55
Other	3	1.3 %	0.00-0.02
None	83	34.9%	0.02-0.40
How often
1- 5 times	143	60.1 %	0.53-0.66
Between 6- 10 times	06	2.5 %	0.04-0.05
Other	04	1.7 %	0.05-0.03
Never screened	85	35.7 %	0.75-0.85
How useful is information
Useful	192	80.7 %	0.75-0.85
Not useful	15	6.3 %	0.29-0.41
Others	31	13 %	0.08-0.17
Health facility screened for pap smear
Public health facility	144	60.5 %	0.54-0.66
Private	09	3.8 %	0.01-0.06
Never performed Pap smear	85	35.7 %	0.29-0.41
Ever screened for VIA
Yes	39	16.4 %	0.11-0.21
No	194	81.5 %	0.77-0.86
Do not Know	05	2.1 %	0.02-0.03
Ever screened for reproductive health Screening such as HIV
Yes	207	86.97%	0.82-0.91
No	30	12.6 %	0.08-0.16
Don’t Know	01	0.4%	0.00-0.01

Finally, the 95% confidence intervals above offer a range within which the true population parameters are likely to fall, providing a measure of precision and reliability for these estimates as evident above.

DISCUSSION AND CONCLUSSION

The results of this study reveal significant insights into the knowledge, attitudes, and practices related to Pap smear screening among women of childbearing age in Okongo health district. The findings underscore both the strengths and areas for improvement in cervical cancer prevention efforts in this district. Additionally, to contextualize the findings of this study, it is valuable to compare them with results from similar studies conducted in different districts, regions or countries. This comparison helps to highlight both common challenges and unique issues related to Pap smear screening across various populations. The findings derived from this research study, study limitation as well as the recommendations of the study will be discussed in this chapter.

While knowledge levels are generally high, there are significant gaps in awareness about the benefits of early detection. Attitudes towards screening are mixed, with a substantial proportion of women harboring unfavorable views, primarily due to worries and misinformation.

Furthermore, the practices related to Pap smear screening are encouraging, with a majority having undergone the procedure. However, there remain significant minorities who have never been screened. Educational interventions targeting misconceptions and emphasizing the importance of early detection could significantly improve participation rates.

In conclusion, enhancing the role of healthcare workers in education and addressing the specific concerns of women regarding Pap smear screenings are crucial steps toward improving cervical cancer prevention efforts in this region. Continued focus on public health education and accessibility of screening services will be essential in achieving higher participation rates and ultimately reducing the incidence of cervical cancer.

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