|Year : 2018 | Volume
| Issue : 1 | Page : 39-49
Health Belief Model-based educational program about cervical cancer prevention on women knowledge and beliefs
Sabah Ramadan Hussein Ahmed1, Amany Saad Mohamed Esa2, Ons Said MohamedEl-zayat3
1 Assistant professor of Maternity and Newborn Health Nursing, Faculty of Nursing, Helwan University, Helwan, Egypt
2 Lecturer of Community Health Nursing, Faculty of Nursing, Helwan University, Helwan, Egypt
3 Faculty of Nursing, Helwan University, Helwan, Egypt
|Date of Submission||01-Oct-2017|
|Date of Acceptance||10-Jan-2018|
|Date of Web Publication||3-Sep-2018|
Amany Saad Mohamed Esa
Lecturer of Community Health Nursing, Faculty of Nursing, Helwan University, Helwan
Source of Support: None, Conflict of Interest: None
Background Awareness of cervical cancer causes and the implementation of screening program can help in reduction of morbidity and mortality among women.
Aim The aim of this study was to examine the effect of nursing educational program based on Health Belief Model (HBM) on women knowledge and beliefs about cervical cancer prevention.
Study design This was a quasi-experimental study (pretest and posttest evaluations).
Setting This study was conducted in El-Maasara Maternal and Child Health Center, Helwan City, Egypt.
Participants and methods A convenience sample of 150 married women was included. The study was conducted from beginning of August 2016 to the end of January 2017 covering a period of 6 months. Two tools were used to conduct this study: a structured cervical cancer knowledge questionnaire and HBM scale. Knowledge and beliefs were assessed using the study tools and then an educational program was designed based on the results of the pretest. The program was implemented followed by evaluation of its effect using the same tools.
Results All the women had poor knowledge score regarding cervical cancer prevention before the program. However, after the program, 16 and 84% of the women had an average and good knowledge, respectively, on cervical cancer prevention. This difference was significant (P<0.001). There were a significant increase in the scores of the perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and the cues to action after the program compared with the scores before the program.
Conclusion After implementation of the nursing educational program regarding cervical cancer prevention for married women, knowledge improved significantly, and there were significant improvements in perceived severity, barriers, benefits, and the cues to action scores after program compared with the scores before program (P≤0.001). These study results supported the study hypotheses.
Recommendations Propagation of educational programs based on HBM on cervical cancer prevention to various age groups would help raise public awareness about cervical cancer and take action for its prevention.
Keywords: cervical cancer prevention, educational program, Health Belief Model
|How to cite this article:|
Ahmed SR, Esa AS, MohamedEl-zayat OS. Health Belief Model-based educational program about cervical cancer prevention on women knowledge and beliefs. Egypt Nurs J 2018;15:39-49
|How to cite this URL:|
Ahmed SR, Esa AS, MohamedEl-zayat OS. Health Belief Model-based educational program about cervical cancer prevention on women knowledge and beliefs. Egypt Nurs J [serial online] 2018 [cited 2019 Jan 19];15:39-49. Available from: http://www.enj.eg.net/text.asp?2018/15/1/39/240355
| Introduction|| |
Cervical cancer is a major health problem, with ∼529 409 new cases occurring worldwide, 274 883 of women (52% of cases) dying of it among the total new cases every year, and ∼86% of cases occurring in developing countries. Unfortunately, 80–90% of the patients die owing to cervical cancer-related causes. The most prominent age of patients having cervical cancer ranges from 35 to 45 years. Cervical cancer claims the lives of women during the most productive years of their life when they may raise children, care for their family, and contribute toward the social and economic life in their community. It is the leading cause of death owing to cancer among women in the developing world and the second most common malignancy in women worldwide after breast cancer (World Health Organization, 2012).
The cervix is a small, donut-shaped structure. It is found at the top of the vagina. It is the entrance to the uterus. Cervical cancer begins in the outer layer of the cervix. This outer layer is called the cervical epithelium. Slight changes begin in epithelial cells. Over time, cells may become cancerous and grow out of control (Eifel et al., 2011). Cervical cancer is a key reproductive health problem for women mainly in the developing countries. Approximately all (99%) cervical cancer cases are related to genital infection with human papilloma virus (HPV), which are the most common sexually transmitted diseases. The pathogenesis can evolve over a period of 10–20 years through precancerous lesions to invasive cancer and ultimately leading to death (Ombech et al., 2012).
HPV is the biggest risk factor for cervical cancer. Other risk factors for cervical cancer including early onset of sexual activity at younger age, multiple sexual partners, over-aged pregnancy risk, lack of genital hygiene, nulliparity and multiparity, alcohol and tobacco use, obesity, prolonged use of oral contraceptive, and positive family history for cervical cancer. Women should do the first cervical cancer screening test 3 years after the first sexual intercourse and then yearly for 3 consecutive years (Ibekwe et al., 2010; Getahun et al., 2013).
Women with early cervical cancer and precancerous lesions usually have no indicators. Symptoms often do not begin until a precancerous lesion becomes a true invasive cancer and metastasizes into nearby tissues. When this occurs, the most common symptoms are as follows: abnormal vaginal bleeding such as bleeding after sex (vaginal intercourse), bleeding after menopause, bleeding and spotting between periods, and having longer or heavier menstrual periods than usual; bleeding after douching; pain during sex (dyspareunia); and abnormal vaginal discharge. More advanced cervical cancer can cause pelvic pain, loss of appetite, weight loss, and reduction in red blood cells (anemia) (Bodurka et al., 2011).
Awareness of cervical cancer causes and implementation of the screening program can help in reducing the risk of disease and death among women. Moreover, they help to decrease disease burden on healthcare services. Another method for prevention of this painful cancer is the HPV vaccine, and in advanced clinical testing, it has been proven to be effective in preventing 65–76% of infections and lesions owing to the viruses. Vaccination can cause protection both directly and indirectly through herd immunity (Centers for Disease Control and Prevention (CDC), 2012; Khatibi et al., 2014).
Health education is an important instrument of public health for motivating people to protect themselves from preventable diseases. However, effective health education programs have to be methodically designed and evidence based. To design a potentially successful intervention of health education for the cervical cancer prevention, it would be valuable to collect information on this subject and on the level of knowledge, beliefs, attitudes, and behavior of women to perform a needs assessment (Koelen and Van, 2012).
The Health Belief Model (HBM) is an appropriate model for needs assessment that is very useful for health developers to plan for intervention practices. According to the HBM, health behavior is the result of a series of central beliefs of people concerning their conceptions of perceived personal susceptibility, perceived severity of the disease, perceived benefits of the new behavior, and perceived barriers for applying a preventive health behavior (Yarbrough and Braden, 2008; Ogden, 2009).
The nurse is the cornerstone in avoidance of cervical cancer owing to being a vital cog in the healthcare delivery system. Fortunately, the nurse plays a key role in health education and promotion. Moreover, the nurse has an important task of imparting information on risk factors, discovering early signs of cervical cancer, and encouraging females to undergo cervical cancer screening frequently (Naik et al., 2012; Mali, 2014).
| Significance of the study|| |
Egypt has a population of 30.55 million, where women aged 19 years and older are at a risk of developing cervical cancer. Recent estimations indicate that every year 866 females are diagnosed with cervical cancer and 373 die owing to it. In Egypt, cervical cancer ranks as the 10th most frequent cancer among women between 19 and 44 years of age. Early detection is critically important in reducing deaths owing to cervical cancer (Ministry of Health and Population Egypt, 2015; Information Centre (ICO) on HPV and Cancer, 2016).
Health education methods present information about cervical cancer prevention and may be the key to changes in cervical cancer knowledge and beliefs as well as preventive behaviors. Moreover, the HBM is one of the models that is commonly used as a guiding framework for health behavior interventions. Therefore, this research was proposed to evaluate the effects of nursing educational program based on HBM on women knowledge and beliefs about cervical cancer prevention.
| Aim of the study|| |
The aim of the study was to examine the effect of nursing educational program based on HBM on women knowledge and beliefs about cervical cancer prevention.
The aim of this study was achieved through the following objectives:
- To assess the level of women knowledge and health beliefs regarding cervical cancer prevention.
- To implement nursing educational program for women.
- To evaluate the effectiveness of the nursing educational program.
The research hypothesis
- The nursing educational program based on HBM for married women about cervical cancer prevention will improve knowledge scores about cervical cancer prevention.
- The nursing educational program based on HBM will positively change health beliefs of women toward cervical cancer prevention.
| Participants and methods|| |
A quasi-experimental pretest and posttest design was used in this study.
The study was carried out at El-Maasara Maternal and Child Health center (MCH), Helwan City, Egypt.
A convenience sample of 150 married women who were referred to MCH center to receive the services was selected randomly out of 1272 married women who attended the MCH center and agreed to participate in the study. The sample size was calculated according to the following formula: n=N/[1+N(e)2].
Data collection tools
Two tools were used to collect data. These tools were developed by the researchers after reviewing the available related literature, and they were written in simple Arabic language. They included the following:
The first tool: structured cervical cancer knowledge questionnaire.
It consisted of three parts:
- Part I: It involved demographic data such as age, educational level, occupation, etc.
- Part II: It included family and obstetric history (family history of cervical cancer, age at marriage, duration of marriage, etc.)
- Part III: It involved 17 questions that assess women’s knowledge regarding cervical cancer (11 yes or no, three multiple choice, and three open questions) such as meaning of cervical cancer, risk factors, symptoms, causes, and vaccination for cervical cancer disease. This part was used as pretest and posttest.
Scoring system for knowledge
The questions were scored as follows: One for a ‘yes’ answer and zero for a ‘no’ answer. The questions that having answers were categorized into: Do not know was given zero, incomplete answer was given one, and complete answer was given two. For multiple-choice questions, correct answer was given one and incorrect answer was given zero. The total knowledge score was calculated by adding the scores for each correct answer. The total score of knowledge ranged from 1 to 20 points, and it was considered ‘poor’ if the knowledge scored from 1 to 10, ‘average’ from 11 to 15, and ‘good’ from 16 to 20 points.
The second tool
It was the HBM scale that was adapted from Champion (1999). It was modified by the researchers after reviewing available related literature.
HBM scale covers five subscales and included 39 items (seven items for perceived susceptibility, 10 items for perceived severity, five items for perceived benefits, 10 items for perceived barrier, and seven items for cues to action). All the items of subscales have three-point Likert scale response choices: agree scores 3 points, neutral scores 2 points, and disagree scores 1 point. The total score ranged from 1 to 117 points, which were scored as follows: 21 for perceived susceptibility, 30 for perceived severity, 15 for perceived benefits, 30 for perceived barrier, and 21 for cues to action.
For measuring content validity of the tools, questionnaires were offered to five academic members of community health nursing and maternal and neonatal health nursing. Then their opinions were considered and final questionnaires were used.
The reliability was evaluated by using Cronbach’s α-coefficient which revealed that the tools had relatively homogenous items. Each dimension had an α of at least 0.7.
The researchers introduced themselves to all healthcare providers and participants and then the participants were informed about the aim of the study to obtain their consent before their participation in the study. The researchers ensured participants that their identities and answers would be kept confidential and would be used only for this study.
A pilot study was carried out to test the clarity of the tools and feasibility of the study. Needed modifications were done in the form of rephrasing of some items. The pilot study was done on 10% of the study sample, involving 15 married women. The pilot subjects were not included in the main study sample.
Before conducting the study, permission was obtained from the director of MCH center to carry out the study. The researchers met the women, and the aim of the study was explained to them. Their informed verbal consent was secured before collecting data. The field work was carried out in 6 months. The study was conducted through four phases: assessment, planning, implementation, and evaluation. These phases were carried out from the beginning of August 2016 to the end of January 2017. The previously mentioned setting was visited by the researchers 3 days/week (Tuesday, Wednesday, and Thursday) from 10.00 a.m. to 1.00 p.m. The questionnaires were distributed and completed by the researchers, and 17–20 questionnaires were completed each week.
The researchers met the women and filled out the questionnaire to assess knowledge regarding cervical cancer prevention, and then the second tool was completed. The data obtained during this phase were considered the basis for evaluation of educational program (pretest).
Planning and implementation phase
After identifying the needs of women in the assessment phase, the researchers developed nursing educational program about cervical cancer prevention based on HBM constructs with simple Arabic language to be suitable for women’s level of understanding. It emphasized the areas of deficit in knowledge about cervical cancer prevention and health beliefs such as follows: definition of cervical cancer, risk factors, causes, signs and symptoms, diagnosis, prevention, and HPV vaccination (benefits, age for vaccination, and who should receive the HPV vaccine). The women were divided into five groups, with each group including 30 women. The program was applied through five sessions, and each session lasted 30–40 min. Educational program hand-out was distributed to each woman. Teaching methods included small group discussions, open discussion, and brain storming. After the session, additional 0.5 h was offered for answering more questions. The program lasted 3 months.
After implementation of the educational program, its effect was assessed by posttest evaluation. The evaluation was done immediately one time after the program using the same tools of pretest evaluation.
The collected data were coded and entered to Statistical Package for Social Sciences windows software, version 20.0 (SPSS Inc., Chicago, Illinois, USA). Categorical data were expressed in number (%) whereas continuous data were expressed as mean±SD. The comparisons between two groups with categorical data were calculated using χ2-test, whereas comparisons between two groups with continuous data were calculated using Student’s t-test. Correlation between variables with continuous data was tested using the correlation coefficient test. Statistical significance was set at P less than 0.05, and a highly statistical significance was considered at P less than 0.001.
| Results|| |
[Table 1] shows that 47.3% of the women in the sample were in the age group 20 to younger than 30 years, 42% were in 30 to younger than 40 years, whereas 10.7% were 40 years or older. Regarding the educational level, the study illustrated that 50% of the sample had secondary education, 18.7% of the sample had basic and university education, and 12.7% was illiterate. Among the women included in this study, 10.7% were employed and 76% of the subjects had insufficient monthly income, whereas 24% of them were found to have sufficient monthly income.
|Table 1 Distribution of the studied sample according to their demographic characteristics (n=150)|
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[Table 2] shows that all the study women had no family history of cervical cancer. The age at marriage of these women ranged from 18 to 28 years, with an average of 22.1±3.1 years, and 36.7% of these women married at the age of 20 years or younger. The average duration of marriage was 8.6±6.3 years (range: 2–24 years). Concerning the number of gravida, 55.3% of the women had gravida of three or less. All of these women used contraceptive method.
|Table 2 Distribution of the studied sample according to their marital and obstetric history (n=150)|
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[Table 3] illustrates that a highly statistically significant difference was found between studied women before and after the program in all knowledge items.
[Table 4] reveals that all the women had poor knowledge score about cervical cancer prevention before the program and improved to 16 and 84% of the women having an average and good level of knowledge, respectively. This difference was significant (P<0.001).
[Table 5],[Table 6],[Table 7],[Table 8],[Table 9] indicate significant differences before and after the program in relation to all items of the perceived susceptibility, all items of the perceived severity, all items of the perceived barriers, all items of the perceived benefits, and all items of the cues to action scores.
|Table 5 Mean scores of Health Belief perceived susceptibility in the study sample before and after program (N=150)|
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|Table 6 Mean scores of Health Belief perceived severity in the study sample before and after program (N=150)|
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|Table 7 Mean scores of Health Belief perceived barriers in the study sample before and after program (N=150)|
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|Table 8 Mean scores of Health Belief perceived benefits in the study sample before and after program (N=150)|
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|Table 9 Mean scores of health belief cues to action in the study sample before and after program (N=150)|
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[Table 10] shows statistically significant positive correlations between total knowledge scores and health belief scores of the study sample before program. There was a significant correlation with the perceived susceptibility (P=0.029) and the perceived severity (P=0.020), significant inverse correlation with the perceived barriers (P=0.025), significant correlation with the perceived benefits (P=0.045), and significant correlation with the cues to action (P=0.030).
|Table 10 Correlation between knowledge score and the health belief of the study sample before program|
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[Table 11] indicates positive statistically significant correlations between total knowledge and health belief scores of the study sample after program. There was significant correlation with the perceived susceptibility (P=0.017), the perceived severity (P=0.016), the perceived barriers (P=0.029), the perceived benefits (P=0.025), and the cues to action (P=0.047).
|Table 11 Correlation between knowledge score and the Health Belief of the study sample after program|
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| Discussion|| |
Cervical cancer is the second cause of women mortality worldwide. Awareness of cervical cancer and its causes and implementation screening program can help in reduction of morbidity and mortality among women and help to reduce disease burden on healthcare services. Cervical cancer is a preventable disease and easily detectable and treatable in early stages (Centers for Disease Control and Prevention (CDC), 2011).
The current study showed that approximately half of the sample was in the age group between 20 to younger than 30 and 30 to younger than 40 years, whereas a minority of the sample was in the age of 40 years. This might be because all women were married and in childbearing period and went to MCH to receive services such as vaccination, follow-up of pregnancy, and use of family planning methods. This result is in agreement with a study by Ehiemere et al. (2015) in Port Harcourt who found that more than one-third of the studied sample was between 20 and 42 years as this study was done among female workers in the university. Moreover, this result was in line with the study by Myriam et al. (2012) in Mexico who found that more than two-thirds of the participants were in this age. This result contradicted the study by Nootan and Ramling (2014) in England who found that majority of the sample was in the age group of 16–20 years. These dissimilarities may be because of the included samples were students and employed during university education, or may be owing to culture differences between Egypt and England.
The findings of the current study illustrated that half of the sample had secondary education, less than one-fifth of the sample had basic and university education, and only a minority of the sample was illiterate. This might be owing to the customs of community in Egypt that not interested by female education and the low socio-economic status that hampers obtaining university education. These findings are in the same line with the findings by Wong et al. (2013) in Malaysia who found that more than half of the studied sample had secondary education and the minority of the sample was illiterate. This result disagrees with the study by Duran (2014) in Turkey who found that the majority of the sample had university education. These dissimilarities may be because Turkey is advanced in terms of education and scientific fields.
The majority of the studied sample was unemployed. This might be because of the existence of a culture where most husbands refuse employment of their wives and also owing to the low level of education of half of the sample. This result contradicts the results of the study by Myriam et al. (2012) in Mexico who found that the majority of the sample was employed.
The present study showed that more than two-thirds of the participants had insufficient monthly income. This might be owing to the high prices and living standard and most women’s husbands working as handicraftsmen. The present study finding was contradicted by Saraiya et al. (2015) who found that more than half of the Hispanic women’s monthly income was sufficient. This is because of the high living standard among Hispanic and development in their country.
The findings of the current study illustrated that none of the participants had family history of cervical cancer. This might be owing to the lack of women awareness about cervical cancer, as some women had family history of hysterectomy without knowing the reason. This finding is in congruence with Davidson and Suwan (2012) who reported that family history of cervical cancer among young women in Thailand was found to be 0.6%. The findings of the present study are in line with the study by Frank and Ehiemere (2017) in Port Harcourt and Rivers State who reported that more than one-tenth had a family history of cervical cancer among young women. This might be because of lack of research studies and health education program introduced to these groups in these areas and the higher incidence rate in Port Harcourt and Rivers State than Egypt.
The present study showed that the average age at marriage of these women was 22.1±3.1 years, and more than half of the participants were married after the age of 20 years. The desire to complete school education before being married might be the reason, where half of the sample had secondary education. These findings were in agreement with the study by Shobeiri et al. (2016) in Iran who found that more than half of the sample married after the age of 20 years.
Concerning the number of the gravidity in the current study, more than half of sample had gravidity of three or more. This might be related to ignorance of some women about different types of family planning methods and they being in the childbearing period. This finding is in accordance with Mupepi et al. (2011) in Zimbabwean who reported that more than two-thirds had gravidity of three. Both Egypt and Zimbabwe are developing countries where having many children is felt as an asset to the family.
Regarding the use of contraceptive method, all of the participants were using contraceptive methods. These may be owing to the fact that the majority of the sample was in the childbearing period and reproductive age and had low economic status in addition to having relatively higher number of children. The present study finding was in contrast to the study by Evelyn et al. (2015) in Jamaica who found that more than one-third do not use contraceptive methods.
Regarding women’s knowledge on cervical cancer prevention, the present study revealed that all the women had poor knowledge score about cervical cancer prevention before the program, which improved drastically after the program. This might be related to the effect of the nursing educational program on knowledge. These study findings supported the study hypothesis number one that the nursing educational program based on HBM for married women about cervical cancer prevention will improve knowledge scores about cervical cancer prevention. These findings are in agreement with the study by Pirzadeh and Mazaheri (2012) in Florida who reported that the mean score of knowledge before the intervention was low regarding Pap smear More Details and cervical cancer, whereas after the educational intervention, the level of knowledge improved significantly. Moreover, the current study was similar to Rashwan et al. (2011) who stated that the students in Malaysia had poor knowledge level of cervical cancer and its prevention. This might be related to needs of educational programs to improve cervical cancer knowledge and awareness of the public.
Regarding the mean scores of constructs of HBM, the present study indicated that the study sample after the program got significantly increase scores regarding the perceived susceptibility, the perceived severity, the perceived barriers, the perceived benefits and the cues to action compared with the scores before the program. This might be because of the identification of the severity and benefits. Moreover, the nursing educational program might increase the awareness and motivation of the women. These study findings supported the study hypothesis number two that the nursing educational program based on HBM will change health beliefs positively toward cervical cancer prevention. Similar findings were obtained in a study carried out on students in Faculties of Benha University by Yossif and EL Sayed (2014) who found that, after implementation of self-learning package, there was a significant improvement in all HBM constructs. Moreover, these results are in agreement with a study carried out in Iran by Shojaeizadeh et al. (2011) who revealed that education based on HBM was effective and improved the perceived susceptibility, severity, benefits, and barriers.
The results of the current study indicated that there was a positive statistically significant correlation between total knowledge score and health belief Model constructs scores after the program. This might be because of nursing educational program, as it provided the participants with valuable information that can affect their health beliefs and preventive behaviors. These findings are in congruence with the study by Kang and Kim (2011) who pointed out that the increased knowledge was associated with increased total health beliefs and improved cervical cancer prevention behaviors. These findings are similar to the study done by Juntasopeepun et al. (2012) who reported that there was a significant positive correlation between total knowledge and total health beliefs scores. Moreover, these results are in agreement with the study by Johnson et al. (2013) who found that most participants provided responses that reflected a high level of knowledge about cervical cancer associated with increase in total health beliefs after intervention.
| Conclusion|| |
According to the results and research hypotheses of the current study, the nursing educational program regarding cervical cancer prevention for married women improved their knowledge and significantly improved HBM constructs compared with the scores before the program (P<0.001). These study results supported the study hypothesis.
On the basis of the results of this study, the following recommendations are proposed:
- Propagation of educational programs should be initiated to raise public awareness about cervical cancer prevention.
- Further researches are needed on a wide scale to assess the barriers of undertaking preventive measures of cervical cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bodurka BD, Morris M, Eifel PJ, Levenback C, Bevers MW, Lucas KR (2011). women with cervical cancer: an outcomes analysis. GynecolOncol 78:187–193.
Centers for Disease Control and Prevention (CDC) (2011). The National Breast and Cervical Cancer Early Detection Program, National Report. Atlanta, GA: US Department of Health and Human Services (HHS).
Centers for Disease Control and Prevention (CDC) (2012). The National Breast and Cervical Cancer Early Detection Program 1991–2002 National Report. Atlanta, GA: U.S. Department of Health and Human Services (HHS), 2012.
Champion VL (1999). Revised susceptibility, benefits, barrier scale for mammography screening. Res Nurs Health 22:341–348.
Davidson P, Suwan N (2012). Human Papillomavirus vaccination intention among young women in Thailand. Asian Pac J Cancer Prev 13:3213–3219.
Duran ET (2014). Examination with the health belief model of women’s attitudes to cervical cancer and early diagnosis in Turkey: a qualitative study. Asian Pac J Cancer Prev 12:2014.
Ehiemere IO, Maureen F, Robinson BGC (2015). Attitude and practice of cervical cancer screening among female health workers in university of Port-Harcourt teaching hospital, Rivers State. J Res Nurs Midwifery 4:072–082.
Eifel PJ, Berek JS, Markman M (2011). Cancer of the cervix, vagina, and vulva. In: DeVita VT, Hellman S, Rosenberg SA, editors. Cancer: principles and practice of oncology. 9th ed. Philadelphia, PA: Lippincott Williams & Wilkins; pp. 1311–1344.
Frank MD, Ehiemere I (2017). Factors influencing uptake of cervical cancer screening among female health workers in University of Port Harcourt Teaching Hospital, Rivers State; J Health Sci Res 2:1–9.
Getahun F, Mazengia F, Abuhay M, Birhanu Z (2013). Comprehensive knowledge about cervical cancer is low among women in Northwest Ethiopia. BMC Cancer 13:2.
Ibekwe CM, Hoque ME, Ntuli-Ngcobo B (2010). Perceived susceptibility of cervical cancer screening among women attending Mahalapye District Hospital, Botswana. South Afr J Epidemiol Infect 25:16–21.
Johnson CE, Mues KE, Mayne SL, Kiblawi AN (2013). Cervical cancer screening among immigrants and ethnic minorities: a systematic review using the Health Belief Model. J Genit Tract Dis 12:232–241.
Juntasopeepun P, Davidson P, Suwan N, Phianmongkhol Y, Srisomboon J (2012). Human papillomavirus vaccination intention among young women in Thailand. Asian Pac J Cancer Prev 13:3213–3219.
Kang H, Kim J (2011). Knowledge, attitudes of human Papillomavirus vaccine, and intention to obtain vaccine among Korean female undergraduate students. Women Health 51:759–776.
Khatibi M, Rasekh HR, Shahverdi Z (2014). Cost-effectiveness evaluation of quadrivalent human papilloma virus vaccine for hpv-related disease in Iran. Iran J Pharm Res 13:225.
Koelen M, Van DBA (2012). Health education and health promotion. Wageningen: Wageningen Academic Publishers.
Mali N (2014). Effect of structured education on knowledge regarding prevention of cervical cancer among A.N.M. students. Int J Sci Res 3:2319–7064.
Ministry of Health and Population, Egypt; El-Zanaty and Associates; ICF International (2015). Egypt Health Issues Survey 2015. Cairo, Egypt and Rockville, MD: Ministry of Health and Population and ICF International.
Mupepi SC, Sampselle CM, Johnson TRB (2011). Knowledge, attitudes, and demographic factors influencing cervical cancer screening behavior of Zimbabwean women. J Women’s Health 20:943–952.
Myriam L, Theresa B, Patrick T (2012). Attitudes towards cervical cancer screening: a study of beliefs among women in Mexico Calif. J Health Promot 4:13–24.
Naik P, Nagaraj K, Nirgude A (2012). Awareness of cervical cancer and effectiveness of educational intervention programme among nursing students in a rural area of Andhra Pradesh, health line. CABI 3:41–445.
Nootan RM, Ramling M (2014). Effect of structured education on knowledge regarding prevention of cervical cancer among A.N.M. students. Int J Sci Res 3:198–1205.
Ogden K (2009). Health education and health promotion. An application of an extended health belief model. Wageningen Academic Publishers, Wageningen University: Wageningen
Ombech E, Muigai A, Wanzala P (2012). Awareness of cervical cancer risk factors and practice of Pap smear testing among female primary school teachers in Kasarani division, Nairobi Kenya. Afr J Health Sci 21:121–132.
Pirzadeh A, Mazaheri M (2012). The effect of education on women’s practice based on the health belief model about Pap Smear Test. Int J Prev Med 3:585–590.
Rashwan H, Lubis SH, Ni KL (2011). Knowledge of Cervical Cancer and Acceptance of HPV Vaccination among Secondary School Students in Sarawak, Malaysia. Asian Pac J Cancer Prev 12:1837.
Saraiya M, Berkowitz Z, Yabroff R (2015). Cervical cancer screening with both Human Papillomavirus and Papanicolau testing vs. Papanicolau testing alone: What screening intervals are physicians recommending? Arch Intern Med 170:977–985.
Shobeiri F, Javad MT, Parsa P, Roshanaei G (2016). Effects of group training based on the Health Belief Model on knowledge and behavior regarding the pap smear test in Iranian women: Aquasi-experimental study. Asian Pac J Cancer Prev 17:2871–2876.
Shojaeizadeh D, Hashemi S, Moeini B, Poorolajal J (2011). The effect of educational program on increasing cervical cancer screening behavior among women in Hamadan, Iran: Applying Health Belief Model. J Res Health Sci 11:20–25.
Wong LP, Khoo EM, Shuib R (2013). Knowledge and awareness of cervical cancer and screening among Malaysian women who have never had a Papsmear: a qualitative study. Singapore Med J 50:49.
Yarbrough SS, Braden CJ (2008). Utility of health belief model as a guide for explaining or predicting breast cancer screening behaviors. J AdvNurs 33:677–688.
Yossif HA, EL Sayed HA (2014). Effect of self learning package based on health belief model on cervical cancer prevention among female university students. IOSR J Nurs Health Sci 3:77–88.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]