Cervical cancer and screening: knowledge, awareness and attitudes of women in a Malta


Cervical cancer, cervical screening, knowledge, attitudes


Objectives. This study comes at an opportune time due to recent introduction of the National Cervical Cancer Screen- ing programme in Malta. It aims to assess the knowledge of 25-64 year-old females on cervical cancer and attitudes towards screening.

Study design. A cross-sectional, telephone-based, quantitative survey conducted in 2017.

Methods. The survey tool was based on the Cervical Cancer Awareness Measure questionnaire and was carried out among a random stratified sample of females of 25-64 years, resident in Malta. Multivariate logistic regression models were applied.

Results. 407 females (85% response rate) were interviewed. Knowledge of cervical cancer risk factors and symptoms was found to be significantly higher in women with a higher level of education (p < 0.001). Cervical screening was attended every 3 years by 69% of respondents. Regular attendees were more likely to have children (p = 0.001), have experienced cancer in a close family member (p = 0.002), and were between 35-44 and 45-54 years old (p < 0.001). The main reasons for non-attendance were embarrassment, fear of the test and fear of the result.

Conclusion. This research provides a better understanding of who are the vulnerable groups with respect to cervical cancer knowledge and screening attendance. Improving health literacy and implementing health promotion campaigns will improve early symptom recognition, risk factor knowledge and attendance for screening.



1. International Agency for Research on Cancer - GLOBOCAN. Cervical Cancer Estimated Incidence, Mortality and Prevalence Worldwide in 2012 [Internet]. World Health Organization. 2012 [cited 2016 Feb 10]. Available from: http://globocan.iarc.fr/old/FactSheets/cancers/cervix-new.asp
2. The Eve Appeal. What Women Know Report on Awareness Levels of Cervical Cancer amongst Women in England. 2010.
3. Arbyn M, Herbert A, Schenck U, Nieminen P, Jordan J, McGoogan E, et al. European guidelines for quality assurance in cervical cancer screening. Vol. 1, Office for Official Publications of the European Communities. 2008.
4. Arbyn M, Castellsague X, de Sanjose S, Bruni L, Saraiya M, Bray F, et al. Worldwide burden of cervical cancer in 2008. Ann Oncol. 2011;22(12):2675–86.
5. Anttila A, Arbyn M, Vuyst H De, Dillner J, Dillner L, Franceschi S, et al. European guidelines for quality assurance in cervical cancer screening - Second Edition Supplements [Internet]. International Agency for Research on Cancer - World Health Organization. 2015. 1-166 p. Available from: http://www.cancer-network.de/cervical/cerv_guidelines.htm\nhttp://scholar.google.com/scholar?hl=en&btnG=Search&q=intitle:European+Guidelines+for+Quality+Assurance+in+Cervical+Cancer+Screening+-+Second+Edition#0\nhttp://scholar.google.com/scholar?hl=en&btn
6. Burr Galea J, Muscat Baron Y. Audit on the frequency of smear tests undertaken prior to pregnancy. Malta Med J [Internet]. 2012;24(November Supplement):163–4. Available from: https://www.um.edu.mt/__data/assets/pdf_file/0003/182946/MMSC_obg.pdf
7. Peirson L, Fitzpatrick-Lewis D, Ciliska D, Warren R. Screening for cervical cancer: a systematic review and meta-analysis. Syst Rev. 2013;2(1):35.
8. Ponti A, Anttila A, Ronco G, Senore C. Against Cancer: Cancer screening in the European Union (2017). 2017.
9. Directorate for Health Information and Research. Malta National Cancer Registry - Cervix Uteri Cancer [Internet]. 2016. Available from: https://deputyprimeminister.gov.mt/en/dhir/Documents/Cancer/Cancer Docs June 2018/Cervix_2016.pdf
10. World Health Organization. European Health Information Gateway [Internet]. Health for All Database. 2019 [cited 2019 Mar 27]. Available from: https://gateway.euro.who.int/en/hfa-explorer/
11. EUROCARE. EUROCARE - Survival of cancer patients in Europe [Internet]. Survival Analysis 2000-2007. 2014 [cited 2017 May 22]. Available from: https://w3.iss.it/site/EU5Results/forms/SA0007.aspx
12. Ministry for Health Malta. The National Cancer Plan for the Maltese Islands 2017-2021 [Internet]. 2017. Available from: http://meae.gov.mt/en/public_consultations/meh-health/documents/ministryforhealth-cancer plan.pdf
13. UCL Health Behaviour Research Centre. Cervical Cancer Awareness Measure (Cervical CAM) Toolkit [Internet]. Cervical Cancer Awareness and Symptoms Initiative (CCASI). 2011. Available from: http://www.cancerresearchuk.org/sites/default/files/health_professional_cervical_cancer_awareness_measure_toolkit_version_2.1_09.02.11.pdf
14. Chang SCH, Woo JST, Gorzalka BB, Brotto LA. A questionnaire study of cervical cancer screening beliefs and practices of Chinese and Caucasian mother-daughter pairs living in Canada. J Obstet Gynaecol Can [Internet]. 2010;32(3):254–62. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med6&NEWS=N&AN=20500970
15. Ekechi C, Olaitan A, Ellis R, Koris J, Amajuoyi A, Marlow LA. Knowledge of cervical cancer and attendance at cervical cancer screening: a survey of Black women in London. BMC Public Health [Internet]. 2014;14(1):1096. Available from: http://www.biomedcentral.com/1471-2458/14/1096
16. Low EL, Simon AE, Lyons J, Romney-Alexander D, Waller J. What do British women know about cervical cancer symptoms and risk factors? Eur J Cancer. 2012;48(16):3001–8.
17. Marmarà D, Marmarà V, Hubbard G. Health beliefs , illness perceptions and determinants of breast screening uptake in Malta : a cross-sectional survey. BMC Public Health. 2017;17:1–19.
18. Damiani G, Basso D, Acampora A, Bianchi CBNA, Silvestrini G, Frisicale EM, et al. The impact of level of education on adherence to breast and cervical cancer screening: Evidence from a systematic review and meta-analysis. Prev Med (Baltim). 2015;81:281–9.
19. Waller J, McCaffery K, Wardle J. Beliefs about the risk factors for cervical cancer in a British population sample. Prev Med (Baltim). 2004;38(6):745–53.
20. Ostensson E, Alder S, Elfstrom KM, Sundstrom K, Zethraeus N, Arbyn M, et al. Barriers to and facilitators of compliance with clinic-based cervical cancer screening: population-based cohort study of women aged 23-60 years. PLoS One. 2015;10(5).
21. Haesebaert J, Lutringer-Magnin D, Kalecinski J, Barone G, Jacquard A-C, Leocmach Y, et al. Disparities of perceptions and practices related to cervical cancer prevention and the acceptability of HPV vaccination according to educational level in a French cross-sectional survey of 18-65 years old women. PLoS One. 2014;9(10).
22. Klug SJ, Hetzer M, Blettner M. Screening for breast and cervical cancer in a large German city: participation, motivation and knowledge of risk factors. Eur J Public Health. 2005;15(1):70–7.
23. Waller J, McCaffery KJ, Forrest S, Wardle J. Human papillomavirus and cervical cancer: issues for biobehavioral and psychosocial research. Ann Behav Med [Internet]. 2004;27(1):68–79. Available from: http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=med5&NEWS=N&AN=14979865
24. Chorley AJ, Marlow LAV, Forster AS, Haddrell JB, Waller J. Experiences of cervical screening and barriers to participation in the context of an organised programme: a systematic review and thematic synthesis. Psychooncology. 2017;26(2):161–72.
25. Brincat AM. Human Papillomavirus Awareness. University of Malta; 2012.
26. Ashok M, Berkowitz Z, Hawkins NA, Tangka F, Saraiya M. Recency of Pap testing and future testing plans among women aged 18-64: analysis of the 2007 Health Information National Trends Survey. J women’s Heal. 2012;21(7):705–12.
27. Cuschieri KS, Horne AW, Szarewski A, Cubie HA. Public awareness of human papillomavirus. J Med Screen. 2006;13(4):201–7.
28. De Vito C, Angeloni C, De Feo E, Marzuillo C, Lattanzi A, Ricciardi W, et al. A large cross-sectional survey investigating the knowledge of cervical cancer risk aetiology and the predictors of the adherence to cervical cancer screening related to mass media campaign. Biomed Res Int. 2014;2014:304602.
29. Directorate for Health Information and Research. European Health Interview Survey 2014/2015 [Internet]. 2017. Available from: http://health.gov.mt/en/dhir/Pages/Surveys/European-Health-Interview-Survey-2014-(EHIS).aspx
30. Burton-Jeangros C, Cullati S, Manor O, Courvoisier DS, Bouchardy C, Guessous I. Cervical cancer screening in Switzerland: cross-sectional trends (1992-2012) in social inequalities. Eur J Public Health. 2016;27(1):167–73.
31. Carrasco-Garrido P, Hernandez-Barrera V, Lopez De Andres A, Jimenez-Trujillo I, Gallardo Pino C, Jimenez-Garcia R. Awareness and uptake of colorectal, breast, cervical and prostate cancer screening tests in Spain. Eur J Public Health. 2014;24(2):264–70.
32. Schoueri-Mychasiw N, McDonald PW. Factors associated with underscreening for cervical cancer among women in Canada. Asian Pac J Cancer Prev. 2013;14(11):6445–50.
33. Seidel D, Becker N, Rohrmann S, Nimptsch K, Linseisen J. Socio-demographic characteristics of participation in the opportunistic German cervical cancer screening programme: results from the EPIC-Heidelberg cohort. J Cancer Res Clin Oncol. 2009;135(4):533–41.
34. Tacken MAJB, Braspenning JCC, Hermens RPMG, Spreeuwenberg PMM, Van Den Hoogen HJM, De Bakker DH, et al. Uptake of cervical cancer screening in The Netherlands is mainly influenced by women’s beliefs about the screening and by the inviting organization. Eur J Public Health. 2007;17(2):178–85.
35. Simou E, Foundoulakis E, Kourlaba G, Maniadakis N. Factors associated with the use of preventive services by women in Greece. Eur J Public Health. 2011;21(4):512–9.
36. Fylan F. Screening for cervical cancer: a review of women’s attitudes, knowledge, and behaviour. Br J Gen Pract. 1998;48(433):1509–14.