Healthcare workers` Compliance with Cervical Cancer Screening Guidelines: Cross-Sectional Study

Healthcare workers` Compliance with Cervical Cancer Screening Guidelines: Cross-Sectional Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Healthcare workers` Compliance with Cervical Cancer Screening Guidelines: Cross-Sectional Study Enjy AE Khorshed, Rania Samy Ezzat, Lamyaa Nasr Asker This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7186684/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Cervical cancer has a massive impact worldwide and is ranked as the 13th most frequent cancer among women in Egypt. It can be successfully treated if it is detected early by regular screening. This study aimed to assess the level of knowledge of healthcare workers regarding cervical cancer screening guidelines and to check the degree of their compliance with those guidelines. Methods A cross-sectional study was conducted among 83 healthcare workers (including physicians and professional nurses) at the Obstetrics and Gynaecology department, Zagazig University Hospitals, using a structured questionnaire assessing knowledge, attitude regarding cervical cancer screening guidelines and evaluating barriers and facilitators to compliance with screening guidelines. Results The mean knowledge score of the participants was 65.06 ± 22.41, and the median 75% ranging from 50% to 75%. The mean attitude score of the participants was 22.71 ± 2.6, and the median 23% ranging from 21% to 24%. Lack of awareness was reported by 63.9% to be the main barrier to compliance, while support from management was reported by 80.7% to be the facilitator to compliance with cervical cancer screening guidelines. There was a statistically significant relation between total attitude score and profession (p < 0.05) and a statistically significant relation between total knowledge score and years of experience (p < 0.05). Conclusion Although a wide agreement of recognition of the importance of cervical cancer screening is present, still existing shortage in knowledge and barriers to compliance with guidelines. This highlights the importance of enhancing the knowledge and clarification of cervical cancer screening guidelines among healthcare workers. Healthcare Workers Compliance Cervical Cancer Screening Guidelines Figures Figure 1 Figure 2 Figure 3 1 Introduction Cervical cancer is a disease that affects sexually active women and is caused by infection with certain high-risk strains of the human papillomavirus ( 1 ). It has a massive impact worldwide, as it is the fourth most common cancer in women, with about 604,127 new cases and 341,831 deaths reported in 2020 globally, 90% of these cases occurring in low and middle-income countries ( 2 ). Moreover, it is the 6th most common cancer in women in the Eastern Mediterranean Region ( 3 ). Cervical cancer is one of the most successfully treatable forms of cancer, if it is detected early by regular screening and managed efficiently ( 4 ). Egypt has a population of 30.55 million women aged 15 years and above who are at risk of developing cervical cancer. Recent estimates imply that 969 women are diagnosed with cervical cancer and 631 die from the disease annually ( 5 ). Also, cervical cancer is ranked as the 13th most frequent cancer among women in Egypt and the 9th furthermost common cancer among women between the ages of 15 and 44 years ( 6 ). In Egypt, about 2.7% of women have cervical HPV-16/18 infection currently, which is determined to cause 78.9% of invasive cervical cancers ( 7 ). There are multiple risk factors for cancer cervix; the most important is Infection by the human papillomavirus (HPV), sexual history ( becoming sexually active at a young age, having many sexual partners, having one partner who is considered high risk), cigarette smoking, immunosuppression, Chlamydia infection and long-term use of oral contraceptives ( 8 ). A significant reduction in the incidence and mortality from cervical cancer has been reported in many countries, mainly in high-income nations, for example, the UK, USA, and European countries ( 9 ). The over-50% decline in cervical cancer incidence and death rates over the last 30 years is thought to be due to (PAP) smear screening, which can detect cervical cancer at an early stage in addition to precancerous abnormalities ( 10 ). According to multiple studies, Physician recommendation is an essential factor in cancer screening performance and obedience( 11 – 13 ). Unfortunately, Egypt, at present, has no systematic national cervical cancer screening program. Healthcare workers have great responsibilities as health educators and promoters. So, inadequate knowledge and low compliance with screening guidelines may lead to an adverse impact on the community in undergoing a Pap smear ( 14 ). So, the screening is entirely dependent on women`s perception and the advice of their healthcare provider ( 15 ). Cervical cancer screening is an important part of women's health care, and the international screening guidelines have been developed to assist women and health professionals to achieve the best outcomes and compliance with them is mandatory. So, our study aimed to assess the level of knowledge of healthcare workers regarding cervical cancer screening guidelines and to check the degree of their compliance with cervical cancer screening guidelines. 2 Methods 2.1 Study design and setting This cross-sectional study was conducted at the Obstetrics and Gynaecology department, Zagazig University Hospitals in Sharkia governorate in the northern part of Egypt for the period between June 2024 to May 2025. 2.2 Sample size and sampling technique All healthcare workers (both physicians and professional nurses) working at the Obstetrics and Gynaecology department, Zagazig University Hospitals, were invited to participate. Those who have been working for less than 1 year were excluded. They were selected by a simple random sampling technique. Sample size was calculated using Open Epi program Version 25 according to the following data: number of healthcare workers of Obstetrics and Gynecology department of Zagazig University hospitals is 233 (158 nurses and 75 working physicians), the percentage of healthcare workers who were familiar with cervical cancer screening guidelines was 2.1% in previous study ( 16 ), confidence limit 2.5 and design effect = 1. So, the calculated sample size was 83. Participants were selected by a simple random sampling technique; they were selected randomly using a workers’ list with proportional allocation to include 56 nurses and 27 working physicians. A pilot study was done using the semi-structured questionnaire on 8 healthcare workers at the Obstetrics and Gynaecology department in a private hospital, to test the feasibility and clarity of questions, and they reported no troubles. The questionnaire took about 10–15 minutes. The results of the pilot study were not included in the results of the study. 2.3 Study tool & data collection A semi-structured, self-administered paper-based questionnaire was prepared based on previous studies ( 16 , 18 , 19 ) that assessed knowledge and attitude related to cervical cancer and screening. Regarding the guidelines, experts in research methodology, Obstetrics and Gynaecology, and Oncology confirmed the validity of the questionnaire before the pilot study. The questionnaire is composed of five parts: The demographic data and occupational status of the respondents. Knowledge regarding cervical cancer screening (5 items). Attitude towards cervical cancer screening guidelines (6 items). Barriers and facilitators to compliance with screening guidelines. Suggestions and additional comments, or experiences related to cervical cancer screening. The questionnaire was written in two languages: English for physicians and Arabic for nurses. The questionnaire was translated into Arabic by one of the authors, who is a native Arabic speaker and fluent in English, then validated through a back translation technique and pilot testing. The two translations were matched; little variations were detected and managed. Language was checked by an English instructor at the American University in Cairo. The study`s tool was validated by performing “face validity”, which is fulfilled by conducting a pilot study and by performing “content validity”, which is fulfilled using a review of the literature, pilot study, and submitting the questionnaire to a board of occupational medicine experts to judge tool items with relevance and appropriateness. The internal consistency of the questionnaire was estimated by calculating Cronbach’s alpha. Healthcare workers’ responses were assessed by calculating the score for each part of the questionnaire as follows: Scoring System for the Questionnaire Section B Knowledge Regarding Cervical Cancer Screening Each correct answer is awarded 1 point, while incorrect or unspecified answers receive 0 points. 1. How often should cervical cancer screening be performed? Correct Answer: Every three years (1 point), Other options: 0 points 2. At what age should the first Pap smear be recommended? Correct Answer: At the age of 21 years (1 point), Other options: 0 points 3. What actions should be taken for HSIL results? Correct Answer: Refer for colposcopy (1 point), Other options: 0 points 4. Awareness of cervical cancer screening guidelines in Egypt? Yes = 1 point No = 0 points 5. Is your health facility compliant with guidelines ? (Not a knowledge question, for assessment only) Total Score for Knowledge: 4 points maximum , then it is transformed into a percentage, and the total score of 100% --------------------------------------------- Section C Attitudes Towards Cervical Cancer Screening Each response is assigned a score based on the level of agreement. Strongly Agree = 5 points Agree = 4 points Neither Agree nor Disagree = 3 points Disagree = 2 points Strongly Disagree = 1 point Statements : Cervical cancer screening is essential. Women should have a Pap smear every 3 years between the ages of 21 and 65. HPV testing is important for women over 30. Regular screening reduces cervical cancer incidence. Lack of symptoms means screening is unnecessary (Reverse scoring: Strongly Disagree = 5 points, Strongly Agree = 1 point) Screening should be a priority in healthcare. Total Score for Attitude: 30 points maximum Section D Barriers and Facilitators This section is not scored but analysed qualitatively for common barriers and facilitators. More than one answer was applicable. 2.4 Statistical analysis Data analysis was conducted using IBM SPSS Statistics software version 25.0 ( 17 ). The collected data were described using appropriate descriptive and inferential statistical techniques. Descriptive Statistics: Qualitative data (e.g., age groups, gender, profession, knowledge and attitude responses) were presented as frequencies and percentages. Quantitative data (e.g., total knowledge and attitude scores) were tested for normality using the Kolmogorov-Smirnov test. Based on the distribution, normally distributed variables were expressed as mean ± standard deviation (SD). Non-normally distributed variables were summarised using the median and interquartile range (IQR). The level of statistical significance was set at p < 0.05. Reliability Testing: The internal consistency of the questionnaire was assessed using Cronbach’s alpha. The results were as follows: Knowledge scale: α = 0.607, indicating acceptable reliability. Attitude scale: α = 0.574 → Acceptable reliability. Both values indicate a moderate level of internal consistency. 3. Comparison Between Groups: a) Profession and Knowledge/Attitude Scores. The Mann-Whitney U test was used to compare knowledge scores between physicians and nurses, as the distribution was non-parametric. The independent samples t-test was used for attitude scores as they were normally distributed. b) Years of Experience and Knowledge/Attitude Scores. Kruskal-Wallis test was used to assess the relation between experience groups and knowledge score. One-way ANOVA was applied to assess differences in attitude scores. 3 Results Most participants (44.6%) were aged more than 50 years, and most of them were females (86.7%). Among the participants studied, 67.5% were nurses and 32.5% were physicians, and most of them (66.3%) had experience of more than 10 years. Table 1 . Regarding Knowledge about Cervical Cancer Screening, most healthcare workers (85.5%) reported that cervical cancer screening should be performed every 3 years, also 65.1% thought that the first Pap smear for women should be done at the age of 30. About 85.5%) supposed that if a Pap smear result comes back with a high-grade squamous intraepithelial lesion, they would refer them to colposcopy, while (14.5%) supposed to repeat the cervical swab. By asking about their awareness of the specific cervical cancer screening guidelines in Egypt, nearly half of the participants (57.8%) admitted they are aware, but (53.0%) thought that their health facility isn`t compliant with the cervical cancer screening guidelines. The mean knowledge score of the participants was 65.06 ± 22.41, and the median 75% ranging from 50% to 75% Table 2 . Table 1 Distribution of the studied subjects according to demographic information Demographic information Participants (n = 83) Age (years) 20–29 years 4 (4.8%) 30–39 years 17 (20.5%) 40–49 years 25 (30.1%) ≥ 50 years 37 (44.6%) Gender Female 72 (86.7%) Male 11 (13.3%) Profession Nurse 56 (67.5%) Physician 27 (32.5%) Experience in Healthcare 1–5 years 6 (7.2%) 6–10 years 22 (26.5%) > 10 years 55 (66.3%) Data is presented as frequency (%) unless otherwise mentioned. Table 2 Distribution of the participants according to knowledge about Cervical Cancer Screening Knowledge Regarding Cervical Cancer Screening Participants (n = 83) Question Answers 1. How often should cervical cancer screening be performed for patients? Annually 1 (1.2%) Every three years 71 (85.5%) Every two years 11 (13.3%) 2. At what age do you recommend the first Pap smear for women? After sexual activity Begins 3 (3.6%) At the age of 21 years 26 (31.3%) At the age of 30 years 54 (65.1%) 3. What actions should be taken if a Pap smear result comes back with a high-grade squamous intraepithelial lesion (HSIL)? Refer for colposcopy 71 (85.5%) Repeat the cervical swab 12 (14.5%) 4. Are you aware of the specific cervical cancer screening guidelines in Egypt? No 35 (42.2%) Yes 48 (57.8%) 5. Do you think your health facility is compliant with the cervical cancer screening guidelines? No 44 (53.0%) Yes 39 (47.0%) Total Knowledge Score (%) Range. 25–100 Mean ± SD. 65.06 ± 22.41 Median (IQR) 75% (50–75) Data is presented as frequency (%) unless otherwise mentioned SD : Standard deviation, IQR : interquartile range. Regarding attitude of participants towards cervical cancer screening guidelines, most healthcare workers (95.2%, 33.7%)) strongly agreed with “Cervical cancer screening is an essential part of women’s health care”, and “HPV testing is important for women over the age of 30” respectively, while (71.1%, 41.0%) agreed with “Women should have a Pap smear every 3 years between ages 21 and 65”, and “Regular cervical cancer screening can significantly reduce the incidence of cervical cancer” respectively. And (33.7%) disagreed with “Cervical cancer screening should be a priority in healthcare settings”. The mean attitude score of the participants was 22.71 ± 2.6, and the median 23% ranging from 21% to 24% Table 3 . Table 3 Distribution of the participants according to Attitudes towards Cervical Cancer Screening Guidelines Attitudes towards Cervical Cancer Screening Guidelines Participants (n = 83) Question Answers 1. Cervical cancer screening is an essential part of women’s health care. Strongly disagree 0 (0.0%) Disagree 0 (0.0%) Neither Agree nor Disagree 1 (1.2%) Agree 3 (3.6%) Strongly Agree 79 95.2%) 2. Women should have a Pap smear every 3 years between the ages of 21 and 65. Strongly disagree 0 (0.0%) Disagree 1 (1.2%) Neither Agree nor Disagree 14 (16.9%) Agree 59 (71.1%) Strongly Agree 9 (10.8%) 3. HPV testing is important for women over the age of 30. Strongly disagree 0 (0.0%) Disagree 4 (4.8%) Neither Agree nor Disagree 27 (32.5%) Agree 24 (28.9%) Strongly Agree 28 (33.7%) 4. Regular cervical cancer screening can significantly reduce the incidence of cervical cancer. Strongly disagree 0 (0.0%) Disagree 7 (8.4%) Neither Agree nor Disagree 23 (27.7%) Agree 34 (41.0%) Strongly Agree 19 (22.9%) 5. Lack of symptoms means that cervical cancer screening is unnecessary. Strongly disagree 15 (18.1%) Disagree 24 (28.9%) Neither Agree nor Disagree 31 (37.3%) Agree 13 (15.7%) Strongly Agree 0 (0.0%) 6. Cervical cancer screening should be a priority in healthcare settings. Strongly disagree 17 (20.5%) Disagree 28 (33.7%) Neither Agree nor Disagree 17 (20.5%) Agree 8 (9.6%) Strongly Agree 13 (15.7%) Total Attitude Score Range. 18–30 Mean ± SD. 22.71 ± 2.6 Median (IQR) 23 ( 21 – 24 ) Data is presented as frequency (%) unless otherwise mentioned SD : Standard deviation, IQR : interquartile range. By studying the barriers and facilitators to compliance, most healthcare workers (63.9%) reported that lack of awareness is the main barrier to compliance with cervical cancer screening guidelines Fig. 1 , while support from management was reported by 80.7% to be the facilitator to compliance with cervical cancer screening guidelines Fig. 2 . By studying the relation between profession and total knowledge & attitude scores, there was a statistically significant relation between total attitude score and profession (p < 0.05) Table 4 , Fig. 3 . Concerning relation between years of experience and total knowledge and attitude score, there was a statistically significant relation between total knowledge score and years of experience (p < 0.05) Table 5, Fig. 4 . Table 4 Relation between Profession and total knowledge and attitude scores Physician (n = 27) Nurse (n = 56) Test of sig. p-value Total Knowledge Score (%) Range. 25–100 25–100 U= 724.0 0.742 Mean ± SD. 66.67 ± 21.93 64.29 ± 22.79 Median (IQR) 75 (50–75) 75 (50–75) Total Attitudes Score Range. 18–30 18–27 t= 2.003 0.049 * Mean ± SD. 23.52 ± 2.11 22.32 ± 2.6 Median (IQR) 23 (21–24.5) 22.5 ( 21 – 24 ) SD : Standard deviation, IQR : interquartile range. U: Mann-Whitney U test, t: t-test *p 10 years (n = 55) Test of sig. p-value Total Knowledge Score (%) Range 25–75 25–100 25–100 H= 6.715 0.035 * Mean ± SD. 54.17 ± 24.58 56.82 ± 19.18 69.55 ± 22.41 Median (IQR) 62.5 (31.25–75) 50 (50–75) 75 (50–75) Total Attitudes Score Range 21–30 18–30 18–27 F= 2.274 0.109 Mean ± SD. 24.33 ± 3.78 23.23 ± 3.22 22.33 ± 2.02 Median (IQR) 23 (21.5–26.75) 23 ( 21 – 25 ) 23 ( 21 – 23 ) SD : Standard deviation, IQR : interquartile range. H : Kruskal-Wallis test, F: one-way ANOVA test *p < 0.05 4 Discussion Cervical cancer awareness, screening procedures, and preventive measures are essential for its prevention and control. Since healthcare workers have a principal role in spreading information about cervical cancer prevention strategies to a wide community, this study shows insights into the knowledge and attitudes about cervical cancer screening among healthcare workers at the Obstetrics and Gynaecology department of Zagazig University Hospitals. This study was performed on 83 healthcare workers, with the majority of participants being nurses 56, 67.5%), females 72, 86.7%), aged ≥ 50 years (44.6%) and having more than 10 years’ work experience. In correspondence with our study, it was found that (52.0%, 59% respectively) of their respondents in healthcare settings were nurses ( 20 , 21 ). That agrees with ( 22 ), who reported the crucial role of nurses in the prevention and early detection of cancer, especially in LMICs (low-middle income countries) as community role models and health educators because of their proximity to their communities. They educate the public about cancer and how to spot its warning signs, like irregular vaginal bleeding and can identify people in the community who are eligible for cancer screening. Similarly, multiple studies in Egypt, Kenya & Ethiopia revealed predominance of female sex among participant nurses with 86%, 65% & 75.4% respectively ( 23 , 24 , 1 ). This is because the nursing profession is occupied by women more than men all over the world. Knowledge Regarding Cervical Cancer Screening Most healthcare workers (85.5%) were in favour of cervical cancer screening to be performed every three years, as per the international guidelines that recommend periodic screening intervals for early detection of cervical cancer ( 3 ). Also, most of participants (65.1%) suggested starting Pap smears at the age of 30, which is in contrast to the recommendations of United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) for women of getting first pap smear at the age of 21 (which is recommended by only 31.3% in our study) followed by pap testing every 3 years ( 25 ). This sounds to be a conservative practice, but it isn`t applied in Egypt, possibly due to resistance based on cultural and traditional constraints. Although updated cervical cancer screening guidelines from the ACS recommend starting screening at age 25 with an HPV test and having HPV testing every 5 years through age 65. But testing with a Pap smear every 3 years is still acceptable ( 25 ). Our finding that 85.5% would refer patients with high-grade squamous intraepithelial lesions (HSIL) for colposcopy aligns with Bray et al. ( 26 ), emphasizing early intervention’s role in reducing cervical cancer’s global burden and indicating an active response to abnormal results. However, the 42.2% unawareness of the local cervical cancer screening guidelines suggests a need for context-specific education, differing from higher awareness in high-income settings like the UK ( 9 ). Attitude Towards Cervical Cancer Screening The hugely favourable attitude, as 95.2% of participants strongly agreed that screening is an essential part of women’s health care, coinciding with worldwide consensus ( 4 , 9 ). Although 71.1% of those surveyed agreed that women need a Pap smear every three years from age 21 to age 65, on the contrary, only 33.7% strongly agreed that women above the age of 30 need HPV testing. This would indicate that, though there is agreement regarding the need for screening, there are not enough details on the actual method of screening guidelines, especially the use of HPV testing. Also, strong agreement on the importance of HPV testing in women over 30, being less than expected, assuming HPV's causation of 78.9% of Egyptian cervical cancers ( 7 ), signifying a gap between knowledge and attitude, possibly due to a lack of HPV testing facilities at Zagazig University Hospitals. The results showed that 41% of the respondents agreed that regular cervical cancer screening has the potential to significantly reduce the incidence of cervical cancer, while 22.9% strongly agreed, indicating belief in the efficacy of the screening which corresponds with ( 27 ) that screening is estimated to reduce the incidence rate of cervical cancer by 50–60%. However, 37.3% did not disagree or agree that "lack of symptoms means cervical cancer screening is unnecessary", suggesting that this is due to a misunderstanding among some of the healthcare providers regarding the asymptomatic nature of cervical cancer during its early stages. Education regarding the natural history of cervical cancer and the importance of screening even in the absence of any symptoms is essential. Barriers and Facilitators to Compliance The current study singled out several barriers to the practice of cervical cancer screening guidelines, where 63.9% of the participants reported that the lack of awareness formed the biggest stumbling block. This is in line with the findings of earlier research carried out in low- and middle-income countries, which reported a lack of awareness of healthcare providers as a major impediment to effective implementation of cervical cancer screening projects ( 16 ). In addition, 20.5% of the respondents admitted the high number of patients as a second barrier, which might be linked to the limitation of facilities and too much workload in healthcare facilities. Conversely, 80.7% of the participants mentioned managerial support as a key factor in improving compliance with the screening guidelines. This highlights the role of institutional support in the long-term feasibility and implementation of cervical cancer screening programs. That concurs with Alkalash et al. ( 1 ), whose research determined that institutional support enhanced screening commitment after education. While contrasts with Sudharshini et al. ( 14 ), where training (rather than management) was the most significant facilitator, possibly due to contrasting institutional cultures (urban India vs. tertiary Egypt). Our results suggested other facilitating factors: awareness campaigns (12%) and availability of additional resources (6%), which are in accordance with WHO recommendations for LMICs ( 4 ). Relationship Between Profession, Experience, and Knowledge/Attitudes This study demonstrated a statistically significant relation between professional title and total attitude score, where physicians reported higher scores compared to nurses. This difference might be owing to differences in training and experience with cervical cancer screening guidelines in both groups. Likewise, a significant relation between years of experience and total knowledge scores, where healthcare professionals with higher years of experience achieved higher scores. This is evidence that experience is an important factor in the ability to develop knowledge and attitude towards cervical cancer screening, and that specific training efforts towards less experienced individuals would be beneficial. Implications for Practice and Policy The findings based on this study have several implications both for policy-making and practical application. Firstly, there is an urgent need to continuously educate and train healthcare workers about the guidelines of cervical cancer screening, particularly in low- and middle-income countries like Egypt. Such an education program should focus on the current methods of screening, particularly the need for HPV screening and the appropriate times to initiate the screening. Secondly, it is critical to gain institutional support to facilitate compliance with determined guidelines. Healthcare facilities should emphasise allocation of adequate resources, aid to provide the ability to comply with screening guidelines and administrative assistance in implementing screening practices. Ultimately, public awareness initiatives are critical to provide education to women on the importance of cervical cancer screening, as well as cultural barriers that restrict participation in screenings. Healthcare workers in the role of educators uphold the impact of the effectiveness of public campaigns, since their knowledge and beliefs provide the building block to successful outcomes. 4.1 Limitations There are various limitations of the current literature. First, the study was conducted at a single institution, thus limiting the generalization of the findings to other settings. Next, the research relied on self-reported data, which might be biased by nature. Lastly, the cross-sectional design of the current study hinders the ability to establish causal relationships. 5 Conclusion This study showed that although a great agreement of recognition of the importance of screening is present, still existing shortage in knowledge and barriers to compliance with guidelines. This highlights the importance of enhancing the knowledge and clarification of cervical cancer screening guidelines among healthcare workers by the establishment of specific training courses, institutional support, and increased public education. 6 Recommendations 1. Educational intervention: Develop standardized training guidelines relevant to cervical cancer screening for healthcare workers with specific attention to the new methods and the importance of HPV screening. 2. Organizational Support: Enable healthcare facilities by offering the required facilities and directions to ensure compliance with screening guidelines set by healthcare professionals. 3. Initiatives of Public Awareness: Create initiatives that increase women's knowledge of the importance of cervical cancer screening and detect and overcome cultural barriers. 4. Future studies should involve large-scale, multisite surveys to strengthen the assessment of healthcare providers' knowledge, attitudes, and compliance with cervical cancer screening guidelines in different settings. Abbreviations ACS American Cancer Society HPV human papillomavirus HSIL high-grade squamous intraepithelial lesion IQR interquartile range LMICs low- and middle-income countries SD standard deviation USPSTF United States Preventive Services Task Force WHO World Health Organization Declarations Acknowledgements The authors are grateful to the nurses and doctors who agreed to participate in this study. Authors’ contributions All authors certify that they have participated sufficiently in the work. LA proposed the research idea. EK and LA prepared the data collection tool. RE had the role of validating the guidelines and data collection. LA had the role of data analysis and interpretation of results. EK had the role of writing the manuscript and preparing it for publication. All authors read and approved the final version of the manuscript. Funding There is no funding source for authors to declare Data availability The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Ethics approval and consent to participate This study has been approved by the institutional review board of the Faculty of Medicine at Zagazig University, IRB#: 203/26- May-2024 Each participant signed an informed consent form after the investigator explained to each patient the nature of the study, its goal, the procedures to be followed, the potential risks, the benefits, the anticipated duration, and any potential discomfort. 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Published 2013. https://doi.org/ 10.4102/phcfm.v5i1.492 Catherine M Kress, Lisa Sharling, Ashli A Owen-Smith, Dawit Desalegn, Henry M Blumberg & Jennifer Goedken. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers, International Journal of Women's Health. 2015; 765-772, https://doi.org/ 10.2147/ijwh.s85138 Mittal H, Gupta PK, Kachroo N, Sinha R, Goyal N. Knowledge, attitude, and practice towards cervical cancer among health care workers of Uttarakhand. Int J Acad Med Pharm 2024; 6 (1); 1004-1010 https://doi.org/10.47009/jamp.2024.6.1.199 Easwaran V, Shorog EM, Alshahrani AA, Mohammad AAS, Sadiq MMJ, Alavudeen SS, Khan NA, Akhtar MS, Almeleebia TM, Alshahrani SM. Knowledge, Attitudes, and Practices Related to Cervical Cancer Prevention and Screening among Female Pharmacy Students at a Public University in a Southern Region of Saudi Arabia. Healthcare. 2023; 11(20):2798. https://doi.org/10.3390/healthcare11202798 Liebermann E, Sego R, Vieira D, Cheng Q, Xu B, Arome M, Azevedo A, Ginsburg O, So WKW. Roles and activities of nurses in cancer prevention and early detection in low- and middle-income countries: A scoping review. Asia Pac J Oncol Nurs. 2023;10(7):100242. https://doi.org/ 10.1016/j.apjon.2023.100242. Kress C, Sharling L, Owen-smith A, Desalegn D, Blumberg M, Goedken J. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers. International Journal of Women's Health, 2015: 7: 765–772. https://doi.org/ 10.2147/IJWH.S85138. Kieti S. Knowledge, attitude and practices on cervical cancer screening and prevention methods among nurses at two Nairobi hospitals in Kenya, submitted in accordance with the requirements for the degree of Master of Arts in nursing science at the university of south Africa, 2016. p:41. http://hdl.handle.net/10500/22760 National Cancer Institute. Cervical Cancer Screening - NCI (2025). Available from: https://www.cancer.gov/types/cervical/screening. Accessed 18 April 2025 Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. https://doi.org/10.3322/caac.21492. Salvatore Vaccarella, Silvia Franceschi, David Zaridze, Mario Poljak, Piret Veerus, Martyn Plummer, Freddie Bray. Preventable fractions of cervical cancer via effective screening in six Baltic, central, and eastern European countries 2017-40: a population-based study. Lancet Oncol. 2016; 17(10):1445-1452. https://doi.org/10.1016/S1470-2045(16)30275-3. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 22 Nov, 2025 Reviews received at journal 11 Nov, 2025 Reviewers agreed at journal 08 Nov, 2025 Reviewers agreed at journal 15 Oct, 2025 Reviewers invited by journal 14 Oct, 2025 Editor assigned by journal 13 Oct, 2025 Submission checks completed at journal 08 Oct, 2025 First submitted to journal 06 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7186684","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":534499125,"identity":"bb49dd43-c787-46c6-8fb7-f61f56ae4fa9","order_by":0,"name":"Enjy AE 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04:19:07","extension":"html","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":127759,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7186684/v1/80ba9ffe098e40fd9ff6559d.html"},{"id":94623354,"identity":"e76cb702-0306-411f-969e-25289337fd54","added_by":"auto","created_at":"2025-10-29 04:19:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":129767,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of the participants according to the main barriers to compliance with cervical cancer screening guidelines\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7186684/v1/f5a8786ece1a0731d82b5a32.png"},{"id":94623480,"identity":"770ff997-b0f0-4c4f-afb4-f7eea1cf4d04","added_by":"auto","created_at":"2025-10-29 04:19:12","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":131571,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of the participants according to facilitators to compliance with cervical cancer screening guidelines\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7186684/v1/8a634b662c85aa09f20f44fc.png"},{"id":94623556,"identity":"1eedd5bd-96ac-47e6-9b8f-2c49799e7bc4","added_by":"auto","created_at":"2025-10-29 04:19:16","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":60251,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRelation between Profession and total attitude scores\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-7186684/v1/7bcfa306530ed5f14ec4f54b.png"},{"id":94623826,"identity":"4510c648-bd09-4129-8011-6a3edd4412d3","added_by":"auto","created_at":"2025-10-29 04:20:01","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2373989,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7186684/v1/a4a4ed0e-3958-4f56-83f2-4b8e17adfad8.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Healthcare workers` Compliance with Cervical Cancer Screening Guidelines: Cross-Sectional Study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eCervical cancer is a disease that affects sexually active women and is caused by infection with certain high-risk strains of the human papillomavirus (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). It has a massive impact worldwide, as it is the fourth most common cancer in women, with about 604,127 new cases and 341,831 deaths reported in 2020 globally, 90% of these cases occurring in low and middle-income countries (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Moreover, it is the 6th most common cancer in women in the Eastern Mediterranean Region (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Cervical cancer is one of the most successfully treatable forms of cancer, if it is detected early by regular screening and managed efficiently (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEgypt has a population of 30.55\u0026nbsp;million women aged 15 years and above who are at risk of developing cervical cancer. Recent estimates imply that 969 women are diagnosed with cervical cancer and 631 die from the disease annually (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Also, cervical cancer is ranked as the 13th most frequent cancer among women in Egypt and the 9th furthermost common cancer among women between the ages of 15 and 44 years (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). In Egypt, about 2.7% of women have cervical HPV-16/18 infection currently, which is determined to cause 78.9% of invasive cervical cancers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThere are multiple risk factors for cancer cervix; the most important is Infection by the human papillomavirus (HPV), sexual history ( becoming sexually active at a young age, having many sexual partners, having one partner who is considered high risk), cigarette smoking, immunosuppression, Chlamydia infection and long-term use of oral contraceptives (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA significant reduction in the incidence and mortality from cervical cancer has been reported in many countries, mainly in high-income nations, for example, the UK, USA, and European countries (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). The over-50% decline in cervical cancer incidence and death rates over the last 30 years is thought to be due to (PAP) smear screening, which can detect cervical cancer at an early stage in addition to precancerous abnormalities (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAccording to multiple studies, Physician recommendation is an essential factor in cancer screening performance and obedience(\u003cspan additionalcitationids=\"CR12\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Unfortunately, Egypt, at present, has no systematic national cervical cancer screening program. Healthcare workers have great responsibilities as health educators and promoters. So, inadequate knowledge and low compliance with screening guidelines may lead to an adverse impact on the community in undergoing a Pap smear (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSo, the screening is entirely dependent on women`s perception and the advice of their healthcare provider (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Cervical cancer screening is an important part of women's health care, and the international screening guidelines have been developed to assist women and health professionals to achieve the best outcomes and compliance with them is mandatory. So, our study aimed to assess the level of knowledge of healthcare workers regarding cervical cancer screening guidelines and to check the degree of their compliance with cervical cancer screening guidelines.\u003c/p\u003e"},{"header":"2 Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Study design and setting\u003c/h2\u003e\u003cp\u003eThis cross-sectional study was conducted at the Obstetrics and Gynaecology department, Zagazig University Hospitals in Sharkia governorate in the northern part of Egypt for the period between June 2024 to May 2025.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Sample size and sampling technique\u003c/h2\u003e\u003cp\u003eAll healthcare workers (both physicians and professional nurses) working at the Obstetrics and Gynaecology department, Zagazig University Hospitals, were invited to participate. Those who have been working for less than 1 year were excluded. They were selected by a simple random sampling technique.\u003c/p\u003e\u003cp\u003eSample size was calculated using Open Epi program Version 25 according to the following data: number of healthcare workers of Obstetrics and Gynecology department of Zagazig University hospitals is 233 (158 nurses and 75 working physicians), the percentage of healthcare workers who were familiar with cervical cancer screening guidelines was 2.1% in previous study (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e), confidence limit 2.5 and design effect\u0026thinsp;=\u0026thinsp;1. So, the calculated sample size was 83. Participants were selected by a simple random sampling technique; they were selected randomly using a workers\u0026rsquo; list with proportional allocation to include 56 nurses and 27 working physicians.\u003c/p\u003e\u003cp\u003eA pilot study was done using the semi-structured questionnaire on 8 healthcare workers at the Obstetrics and Gynaecology department in a private hospital, to test the feasibility and clarity of questions, and they reported no troubles. The questionnaire took about 10\u0026ndash;15 minutes. The results of the pilot study were not included in the results of the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Study tool \u0026amp; data collection\u003c/h2\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eA semi-structured, self-administered paper-based questionnaire\u003c/span\u003e was prepared based on previous studies (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e) that assessed knowledge and attitude related to cervical cancer and screening. Regarding the guidelines, experts in research methodology, Obstetrics and Gynaecology, and Oncology confirmed the validity of the questionnaire before the pilot study.\u003c/p\u003e\u003cp\u003eThe questionnaire is composed of five parts:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eThe demographic data and occupational status of the respondents.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eKnowledge regarding cervical cancer screening (5 items).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e Attitude towards cervical cancer screening guidelines (6 items).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eBarriers and facilitators to compliance with screening guidelines.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSuggestions and additional comments, or experiences related to cervical cancer screening.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eThe questionnaire was written in two languages: English for physicians and Arabic for nurses. The questionnaire was translated into Arabic by one of the authors, who is a native Arabic speaker and fluent in English, then validated through a back translation technique and pilot testing. The two translations were matched; little variations were detected and managed. Language was checked by an English instructor at the American University in Cairo.\u003c/p\u003e\u003cp\u003eThe study`s tool was validated by performing \u0026ldquo;face validity\u0026rdquo;, which is fulfilled by conducting a pilot study and by performing \u0026ldquo;content validity\u0026rdquo;, which is fulfilled using a review of the literature, pilot study, and submitting the questionnaire to a board of occupational medicine experts to judge tool items with relevance and appropriateness. The internal consistency of the questionnaire was estimated by calculating Cronbach\u0026rsquo;s alpha. Healthcare workers\u0026rsquo; responses were assessed by calculating the score for each part of the questionnaire as follows:\u003c/p\u003e\u003cp\u003e\u003cb\u003eScoring System for the Questionnaire\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSection B\u003c/strong\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eKnowledge Regarding Cervical Cancer Screening\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003eEach correct answer is awarded 1 point, while incorrect or unspecified answers receive 0 points.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003e1. How often should cervical cancer screening be performed?\u003c/h3\u003e\n\u003cp\u003eCorrect Answer: Every three years (1 point), Other options: 0 points\u003c/p\u003e\n\u003ch3\u003e2. At what age should the first Pap smear be recommended?\u003c/h3\u003e\n\u003cp\u003eCorrect Answer: At the age of 21 years (1 point), Other options: 0 points\u003c/p\u003e\n\u003ch3\u003e3. What actions should be taken for HSIL results?\u003c/h3\u003e\n\u003cp\u003eCorrect Answer: Refer for colposcopy (1 point), Other options: 0 points\u003c/p\u003e\n\u003ch3\u003e4. Awareness of cervical cancer screening guidelines in Egypt?\u003c/h3\u003e\n\u003cp\u003eYes\u0026thinsp;=\u0026thinsp;1 point\u003c/p\u003e\u003cp\u003eNo\u0026thinsp;=\u0026thinsp;0 points\u003c/p\u003e\u003cp\u003e\u003cb\u003e5. Is your health facility compliant with guidelines\u003c/b\u003e? (Not a knowledge question, for assessment only)\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eTotal Score for Knowledge: 4 points maximum\u003c/b\u003e, then it is transformed into a percentage, and the total score of 100%\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e---------------------------------------------\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSection C\u003c/strong\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eAttitudes Towards Cervical Cancer Screening\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003e Each response is assigned a score based on the level of agreement.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eStrongly Agree\u0026thinsp;=\u0026thinsp;5 points\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eAgree\u0026thinsp;=\u0026thinsp;4 points\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNeither Agree nor Disagree\u0026thinsp;=\u0026thinsp;3 points\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eDisagree\u0026thinsp;=\u0026thinsp;2 points\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eStrongly Disagree\u0026thinsp;=\u0026thinsp;1 point\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eStatements\u003c/span\u003e:\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eCervical cancer screening is essential.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWomen should have a Pap smear every 3 years between the ages of 21 and 65.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eHPV testing is important for women over 30.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eRegular screening reduces cervical cancer incidence.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLack of symptoms means screening is unnecessary (Reverse scoring: Strongly Disagree\u0026thinsp;=\u0026thinsp;5 points, Strongly Agree\u0026thinsp;=\u0026thinsp;1 point)\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eScreening should be a priority in healthcare.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eTotal Score for Attitude: 30 points maximum\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eSection D\u003c/strong\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eBarriers and Facilitators\u003c/span\u003e\u003c/p\u003e\u003c/p\u003e\u003cp\u003eThis section is not scored but analysed qualitatively for common barriers and facilitators.\u003c/p\u003e\u003cp\u003eMore than one answer was applicable.\u003c/p\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Statistical analysis\u003c/h2\u003e\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eData analysis was conducted using IBM SPSS Statistics software version 25.0 (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). The collected data were described using appropriate descriptive and inferential statistical techniques.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eDescriptive Statistics: Qualitative data (e.g., age groups, gender, profession, knowledge and attitude responses) were presented as frequencies and percentages. Quantitative data (e.g., total knowledge and attitude scores) were tested for normality using the Kolmogorov-Smirnov test. Based on the distribution, normally distributed variables were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD). Non-normally distributed variables were summarised using the median and interquartile range (IQR). The level of statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eReliability Testing: The internal consistency of the questionnaire was assessed using Cronbach\u0026rsquo;s alpha. The results were as follows:\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eKnowledge scale: α\u0026thinsp;=\u0026thinsp;0.607, indicating acceptable reliability.\u003c/p\u003e\u003cp\u003eAttitude scale: α\u0026thinsp;=\u0026thinsp;0.574 \u0026rarr; Acceptable reliability.\u003c/p\u003e\u003cp\u003eBoth values indicate a moderate level of internal consistency.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e3. Comparison Between Groups: a) Profession and Knowledge/Attitude Scores. The Mann-Whitney U test was used to compare knowledge scores between physicians and nurses, as the distribution was non-parametric. The independent samples t-test was used for attitude scores as they were normally distributed. b) Years of Experience and Knowledge/Attitude Scores. Kruskal-Wallis test was used to assess the relation between experience groups and knowledge score. One-way ANOVA was applied to assess differences in attitude scores.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cp\u003eMost participants (44.6%) were aged more than 50 years, and most of them were females (86.7%). Among the participants studied, 67.5% were nurses and 32.5% were physicians, and most of them (66.3%) had experience of more than 10 years. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eRegarding Knowledge about Cervical Cancer Screening, most healthcare workers (85.5%) reported that cervical cancer screening should be performed every 3 years, also 65.1% thought that the first Pap smear for women should be done at the age of 30. About 85.5%) supposed that if a Pap smear result comes back with a high-grade squamous intraepithelial lesion, they would refer them to colposcopy, while (14.5%) supposed to repeat the cervical swab. By asking about their awareness of the specific cervical cancer screening guidelines in Egypt, nearly half of the participants (57.8%) admitted they are aware, but (53.0%) thought that their health facility isn`t compliant with the cervical cancer screening guidelines. The mean knowledge score of the participants was 65.06\u0026thinsp;\u0026plusmn;\u0026thinsp;22.41, and the median 75% ranging from 50% to 75% Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the studied subjects according to demographic information\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemographic information\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;29 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4 (4.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e30\u0026ndash;39 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e17 (20.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e40\u0026ndash;49 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e25 (30.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;50 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e37 (44.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eGender\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e72 (86.7%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e11 (13.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eProfession\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e56 (67.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e27 (32.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eExperience in Healthcare\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;5 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6 (7.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e22 (26.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e55 (66.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData is presented as frequency (%) unless otherwise mentioned.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the participants according to knowledge about Cervical Cancer Screening\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eKnowledge Regarding Cervical Cancer Screening\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnswers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e1. \u003cb\u003eHow often should cervical cancer screening be performed for patients?\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAnnually\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.2%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEvery three years\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (85.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eEvery two years\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11 (13.3%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e\u003cb\u003e2. At what age do you recommend the first Pap smear for women?\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAfter sexual activity\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eBegins\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.6%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAt the age of 21 years\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (31.3%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAt the age of 30 years\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e54 (65.1%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e3. What actions should be taken if a Pap smear result comes back with a high-grade squamous intraepithelial lesion (HSIL)?\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRefer for colposcopy\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e71 (85.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eRepeat the cervical swab\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e12 (14.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e4. Are you aware of the specific cervical cancer screening guidelines in Egypt?\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35 (42.2%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (57.8%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003e\u003cb\u003e5. Do you think your health facility is compliant with the cervical cancer screening guidelines?\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNo\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (53.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eYes\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e39 (47.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Knowledge Score (%)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRange.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e65.06\u0026thinsp;\u0026plusmn;\u0026thinsp;22.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMedian (IQR)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75% (50\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData is presented as frequency (%) unless otherwise mentioned\u003c/p\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e: Standard deviation, \u003cb\u003eIQR\u003c/b\u003e: interquartile range.\u003c/p\u003e\u003cp\u003eRegarding attitude of participants towards cervical cancer screening guidelines, most healthcare workers (95.2%, 33.7%)) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003estrongly agreed\u003c/span\u003e with \u0026ldquo;Cervical cancer screening is an essential part of women\u0026rsquo;s health care\u0026rdquo;, and \u0026ldquo;HPV testing is important for women over the age of 30\u0026rdquo; respectively, while (71.1%, 41.0%) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eagreed\u003c/span\u003e with \u0026ldquo;Women should have a Pap smear every 3 years between ages 21 and 65\u0026rdquo;, and \u0026ldquo;Regular cervical cancer screening can significantly reduce the incidence of cervical cancer\u0026rdquo; respectively. And (33.7%) \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003edisagreed\u003c/span\u003e with \u0026ldquo;Cervical cancer screening should be a priority in healthcare settings\u0026rdquo;. The mean attitude score of the participants was 22.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6, and the median 23% ranging from 21% to 24% Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eDistribution of the participants according to Attitudes towards Cervical Cancer Screening Guidelines\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eAttitudes towards Cervical Cancer Screening Guidelines\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eParticipants\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;83)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestion\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAnswers\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e1. Cervical cancer screening is an essential part of women\u0026rsquo;s health care.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.2%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3 (3.6%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e79 95.2%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e2. Women should have a Pap smear every 3 years between the ages of 21 and 65.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.2%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (16.9%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59 (71.1%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9 (10.8%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e3. HPV testing is important for women over the age of 30.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (4.8%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27 (32.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (28.9%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (33.7%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e4. Regular cervical cancer screening can significantly reduce the incidence of cervical cancer.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7 (8.4%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (27.7%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e34 (41.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (22.9%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e5. Lack of symptoms means that cervical cancer screening is unnecessary.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (18.1%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (28.9%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (37.3%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (15.7%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0 (0.0%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e\u003cp\u003e\u003cb\u003e6. Cervical cancer screening should be a priority in healthcare settings.\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (20.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28 (33.7%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eNeither Agree nor Disagree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (20.5%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eAgree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (9.6%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003eStrongly Agree\u003c/b\u003e\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (15.7%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Attitude Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eRange.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eData is presented as frequency (%) unless otherwise mentioned\u003c/p\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e: Standard deviation, \u003cb\u003eIQR\u003c/b\u003e: interquartile range.\u003c/p\u003e\u003cp\u003e By studying the barriers and facilitators to compliance, most healthcare workers (63.9%) reported that lack of awareness is the main barrier to compliance with cervical cancer screening guidelines Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, while support from management was reported by 80.7% to be the facilitator to compliance with cervical cancer screening guidelines Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eBy studying the relation between profession and total knowledge \u0026amp; attitude scores, there was a statistically significant relation between total attitude score and profession (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Concerning relation between years of experience and total knowledge and attitude score, there was a statistically significant relation between total knowledge score and years of experience (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) \u003cb\u003eTable\u0026nbsp;5, Fig.\u0026nbsp;4\u003c/b\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelation between Profession and total knowledge and attitude scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePhysician\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;27)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNurse\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;56)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eTest of sig.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Knowledge Score (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRange.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eU=\u003c/p\u003e\u003cp\u003e724.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.742\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e66.67\u0026thinsp;\u0026plusmn;\u0026thinsp;21.93\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.29\u0026thinsp;\u0026plusmn;\u0026thinsp;22.79\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e75 (50\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75 (50\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Attitudes Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRange.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u0026ndash;27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003et=\u003c/p\u003e\u003cp\u003e2.003\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.049\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.52\u0026thinsp;\u0026plusmn;\u0026thinsp;2.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.32\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (21\u0026ndash;24.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.5 (\u003cspan additionalcitationids=\"CR22 CR23\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003eSD\u003c/b\u003e: Standard deviation, \u003cb\u003eIQR\u003c/b\u003e: interquartile range. \u003cb\u003eU: Mann-Whitney U test, t: t-test\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cb\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/b\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eRelation between years of experience and total knowledge and attitude scores\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u0026ndash;5 Years\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6\u0026ndash;10 Years\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026gt;\u0026thinsp;10 years\u003c/p\u003e\u003cp\u003e(n\u0026thinsp;=\u0026thinsp;55)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eTest of sig.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal Knowledge Score (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e25\u0026ndash;75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25\u0026ndash;100\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eH=\u003c/p\u003e\u003cp\u003e6.715\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.035\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e54.17\u0026thinsp;\u0026plusmn;\u0026thinsp;24.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e56.82\u0026thinsp;\u0026plusmn;\u0026thinsp;19.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e69.55\u0026thinsp;\u0026plusmn;\u0026thinsp;22.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e62.5 (31.25\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e50 (50\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75 (50\u0026ndash;75)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTotal Attitudes Score\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRange\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u0026ndash;30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e18\u0026ndash;27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eF=\u003c/p\u003e\u003cp\u003e2.274\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003e0.109\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e24.33\u0026thinsp;\u0026plusmn;\u0026thinsp;3.78\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e22.33\u0026thinsp;\u0026plusmn;\u0026thinsp;2.02\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMedian (IQR)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23 (21.5\u0026ndash;26.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (\u003cspan additionalcitationids=\"CR22 CR23 CR24\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e23 (\u003cspan additionalcitationids=\"CR22\" citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e\u003cb\u003eSD\u003c/b\u003e: Standard deviation, \u003cb\u003eIQR\u003c/b\u003e: interquartile range. \u003cb\u003eH\u003c/b\u003e: Kruskal-Wallis test, F: one-way ANOVA test\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"6\"\u003e*p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eCervical cancer awareness, screening procedures, and preventive measures are essential for its prevention and control. Since healthcare workers have a principal role in spreading information about cervical cancer prevention strategies to a wide community, this study shows insights into the knowledge and attitudes about cervical cancer screening among healthcare workers at the Obstetrics and Gynaecology department of Zagazig University Hospitals.\u003c/p\u003e\u003cp\u003eThis study was performed on 83 healthcare workers, with the majority of participants being nurses 56, 67.5%), females 72, 86.7%), aged\u0026thinsp;\u0026ge;\u0026thinsp;50 years (44.6%) and having more than 10 years\u0026rsquo; work experience. In correspondence with our study, it was found that (52.0%, 59% respectively) of their respondents in healthcare settings were nurses (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). That agrees with (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e), who reported the crucial role of nurses in the prevention and early detection of cancer, especially in LMICs (low-middle income countries) as community role models and health educators because of their proximity to their communities. They educate the public about cancer and how to spot its warning signs, like irregular vaginal bleeding and can identify people in the community who are eligible for cancer screening. Similarly, multiple studies in Egypt, Kenya \u0026amp; Ethiopia revealed predominance of female sex among participant nurses with 86%, 65% \u0026amp; 75.4% respectively (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). This is because the nursing profession is occupied by women more than men all over the world.\u003c/p\u003e\u003cp\u003e\u003cb\u003eKnowledge Regarding Cervical Cancer Screening\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMost healthcare workers (85.5%) were in favour of cervical cancer screening to be performed every three years, as per the international guidelines that recommend periodic screening intervals for early detection of cervical cancer (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Also, most of participants (65.1%) suggested starting Pap smears at the age of 30, which is in contrast to the recommendations of United States Preventive Services Task Force (USPSTF) and the American Cancer Society (ACS) for women of getting first pap smear at the age of 21 (which is recommended by only 31.3% in our study) followed by pap testing every 3 years (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). This sounds to be a conservative practice, but it isn`t applied in Egypt, possibly due to resistance based on cultural and traditional constraints.\u003c/p\u003e\u003cp\u003e Although updated cervical cancer screening guidelines from the ACS recommend starting screening at age 25 with an HPV test and having HPV testing every 5 years through age 65. But testing with a Pap smear every 3 years is still acceptable (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOur finding that 85.5% would refer patients with high-grade squamous intraepithelial lesions (HSIL) for colposcopy aligns with \u003cb\u003eBray et al.\u003c/b\u003e (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), emphasizing early intervention\u0026rsquo;s role in reducing cervical cancer\u0026rsquo;s global burden and indicating an active response to abnormal results. However, the 42.2% unawareness of the local cervical cancer screening guidelines suggests a need for context-specific education, differing from higher awareness in high-income settings like the UK (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eAttitude Towards Cervical Cancer Screening\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe hugely favourable attitude, as 95.2% of participants strongly agreed that screening is an essential part of women\u0026rsquo;s health care, coinciding with worldwide consensus (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eAlthough 71.1% of those surveyed agreed that women need a Pap smear every three years from age 21 to age 65, on the contrary, only 33.7% strongly agreed that women above the age of 30 need HPV testing. This would indicate that, though there is agreement regarding the need for screening, there are not enough details on the actual method of screening guidelines, especially the use of HPV testing.\u003c/p\u003e\u003cp\u003eAlso, strong agreement on the importance of HPV testing in women over 30, being less than expected, assuming HPV's causation of 78.9% of Egyptian cervical cancers (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e), signifying a gap between knowledge and attitude, possibly due to a lack of HPV testing facilities at Zagazig University Hospitals.\u003c/p\u003e\u003cp\u003eThe results showed that 41% of the respondents agreed that regular cervical cancer screening has the potential to significantly reduce the incidence of cervical cancer, while 22.9% strongly agreed, indicating belief in the efficacy of the screening which corresponds with (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e) that screening is estimated to reduce the incidence rate of cervical cancer by 50\u0026ndash;60%. However, 37.3% did not disagree or agree that \"lack of symptoms means cervical cancer screening is unnecessary\", suggesting that this is due to a misunderstanding among some of the healthcare providers regarding the asymptomatic nature of cervical cancer during its early stages. Education regarding the natural history of cervical cancer and the importance of screening even in the absence of any symptoms is essential.\u003c/p\u003e\u003cp\u003e\u003cb\u003eBarriers and Facilitators to Compliance\u003c/b\u003e\u003c/p\u003e\u003cp\u003e The current study singled out several barriers to the practice of cervical cancer screening guidelines, where 63.9% of the participants reported that the lack of awareness formed the biggest stumbling block. This is in line with the findings of earlier research carried out in low- and middle-income countries, which reported a lack of awareness of healthcare providers as a major impediment to effective implementation of cervical cancer screening projects (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn addition, 20.5% of the respondents admitted the high number of patients as a second barrier, which might be linked to the limitation of facilities and too much workload in healthcare facilities.\u003c/p\u003e\u003cp\u003e Conversely, 80.7% of the participants mentioned managerial support as a key factor in improving compliance with the screening guidelines. This highlights the role of institutional support in the long-term feasibility and implementation of cervical cancer screening programs. That concurs with \u003cb\u003eAlkalash et al.\u003c/b\u003e (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e), whose research determined that institutional support enhanced screening commitment after education. While contrasts with \u003cb\u003eSudharshini et al.\u003c/b\u003e (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e), where training (rather than management) was the most significant facilitator, possibly due to contrasting institutional cultures (urban India vs. tertiary Egypt). Our results suggested other facilitating factors: awareness campaigns (12%) and availability of additional resources (6%), which are in accordance with WHO recommendations for LMICs (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cb\u003eRelationship Between Profession, Experience, and Knowledge/Attitudes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThis study demonstrated a statistically significant relation between professional title and total attitude score, where physicians reported higher scores compared to nurses. This difference might be owing to differences in training and experience with cervical cancer screening guidelines in both groups. Likewise, a significant relation between years of experience and total knowledge scores, where healthcare professionals with higher years of experience achieved higher scores. This is evidence that experience is an important factor in the ability to develop knowledge and attitude towards cervical cancer screening, and that specific training efforts towards less experienced individuals would be beneficial.\u003c/p\u003e\u003cp\u003e\u003cb\u003eImplications for Practice and Policy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe findings based on this study have several implications both for policy-making and practical application. Firstly, there is an urgent need to continuously educate and train healthcare workers about the guidelines of cervical cancer screening, particularly in low- and middle-income countries like Egypt. Such an education program should focus on the current methods of screening, particularly the need for HPV screening and the appropriate times to initiate the screening.\u003c/p\u003e\u003cp\u003e Secondly, it is critical to gain institutional support to facilitate compliance with determined guidelines. Healthcare facilities should emphasise allocation of adequate resources, aid to provide the ability to comply with screening guidelines and administrative assistance in implementing screening practices.\u003c/p\u003e\u003cp\u003eUltimately, public awareness initiatives are critical to provide education to women on the importance of cervical cancer screening, as well as cultural barriers that restrict participation in screenings. Healthcare workers in the role of educators uphold the impact of the effectiveness of public campaigns, since their knowledge and beliefs provide the building block to successful outcomes.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Limitations\u003c/h2\u003e\u003cp\u003eThere are various limitations of the current literature. First, the study was conducted at a single institution, thus limiting the generalization of the findings to other settings. Next, the research relied on self-reported data, which might be biased by nature. Lastly, the cross-sectional design of the current study hinders the ability to establish causal relationships.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003e This study showed that although a great agreement of recognition of the importance of screening is present, still existing shortage in knowledge and barriers to compliance with guidelines. This highlights the importance of enhancing the knowledge and clarification of cervical cancer screening guidelines among healthcare workers by the establishment of specific training courses, institutional support, and increased public education.\u003c/p\u003e"},{"header":"6 Recommendations","content":"\u003cp\u003e1.\u0026nbsp;\u0026nbsp;Educational intervention: Develop standardized training guidelines relevant to cervical cancer screening for healthcare workers with specific attention to the new methods and the importance of HPV screening.\u003c/p\u003e\n\u003cp\u003e2.\u0026nbsp;\u0026nbsp;Organizational Support: Enable healthcare facilities by offering the required facilities and directions to ensure compliance with screening guidelines set by healthcare professionals.\u003c/p\u003e\n\u003cp\u003e3.\u0026nbsp;\u0026nbsp;Initiatives of Public Awareness: Create initiatives that increase women\u0026apos;s knowledge of the importance of cervical cancer screening and detect and overcome cultural barriers.\u003c/p\u003e\n\u003cp\u003e4. \u0026nbsp;Future studies should involve large-scale, multisite surveys to strengthen the assessment of healthcare providers\u0026apos; knowledge, attitudes, and compliance with cervical cancer screening guidelines in different settings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eACS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAmerican Cancer Society\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHPV\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehuman papillomavirus\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eHSIL\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ehigh-grade squamous intraepithelial lesion\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eIQR\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003einterquartile range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eLMICs\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003elow- and middle-income countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eSD\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003estandard deviation\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eUSPSTF\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eUnited States Preventive Services Task Force\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u003cb\u003eWHO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors are grateful to the nurses and doctors who agreed to participate in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors certify that they have participated sufficiently in the work.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eLA\u003c/strong\u003e proposed the research idea. \u003cstrong\u003eEK\u003c/strong\u003e and \u003cstrong\u003eLA\u003c/strong\u003e prepared the data collection tool. \u003cstrong\u003eRE\u003c/strong\u003e had the role of validating the guidelines and data collection. \u003cstrong\u003eLA\u003c/strong\u003e had the role of data analysis and interpretation of results. \u0026nbsp;\u003cstrong\u003eEK\u003c/strong\u003e had the role of writing the manuscript and preparing it for publication. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere is no funding source for authors to declare\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study has been approved by the institutional review board of the Faculty of Medicine at Zagazig University, \u003cstrong\u003eIRB#: 203/26- May-2024\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach participant signed an informed consent form after the investigator explained to each patient the nature of the study, its goal, the procedures to be followed, the potential risks, the benefits, the anticipated duration, and any potential discomfort. Written informed consent was obtained from each participant after explaining the study objectives and assuring them of the confidentiality of their responses. Confidentiality of data was ensured and maintained throughout the whole study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors have no competing interests to declare.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAlkalash S, Al-Kilany O, Shams El-Deen A. Evaluation of an educational program regarding cancer cervix for health care workers in family health facilities. The Egyptian Family Medicine Journal. 2020; 4(1), 6\u0026ndash;23. https://doi.org/10.21608/efmj.2020.90198 \u003c/li\u003e\n\u003cli\u003eGultekin M, Ramirez PT, Broutet N, Hutubessy R. World Health Organization call for action to eliminate cervical cancer globally. Int J Gynecol Cancer. 2020;30(4):426\u0026ndash;427. https://doi.org/10.1136/ijgc-2020-001285.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO1). Cervical cancer (2023). Available from: https://www.who.int/news-room/fact-sheets/detail/cervical-cancer . Accessed 18 January 2025\u003c/li\u003e\n\u003cli\u003eHealth Organization (WHO2). WHO EMRO: Cervical Cancer Awareness Month 2023. Available from: https://www.emro.who.int/noncommunicable-diseases/campaigns/cervical-cancer-awareness-month-2023.html. Accessed 24 January 2025\u003c/li\u003e\n\u003cli\u003eElazab M, Ali O, Ramadan M, Hassan M, Aljedaani H, Gardner F. The Prevalence of Human Papilloma Virus (HPV) among Egyptian Women and Its Impact: An Observational Study. Open Journal of Obstetrics and Gynecology. 2021;11, 879-884. https://doi.org/10.4236/ojog.2021.117082.\u003c/li\u003e\n\u003cli\u003eBruni LAG, Serrano B, Mena M, Collado JJ, G\u0026oacute;mez D, Mu\u0026ntilde;oz J, Bosch FX, de Sanjos\u0026eacute; S. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Egypt. Summary Report 10 March 2023. https://hpvcentre.net/statistics/reports/XWX.pdf\u003c/li\u003e\n\u003cli\u003eAl-Rifai R, Loney T. Factors associated with a lack of knowledge of performing breast self-examination and unawareness of cervical cancer screening services: Evidence from the Egypt Health Issues Survey. Asian Pacific Journal of Cancer Prevention.2017; 18(10), 2763\u0026ndash;2769. https://doi.org/ 10.22034/APJCP.2017.18.10.2763\u003c/li\u003e\n\u003cli\u003eAmerican Cancer Society. (2020). Cervical cancer: Risk factors for cervical cancer. Available from: https://www.cancer.org/cancer/types/cervical-cancer/causes-risks-prevention/risk-factors.html. Accessed 16 February 2025\u003c/li\u003e\n\u003cli\u003eWilailak S, Kengsakul M, Kehoe S. Worldwide initiatives to eliminate cervical cancer. International Journal of Gynecology \u0026amp; Obstetrics. 2021; 155(Suppl. 1), 102\u0026ndash;106. https://doi.org/10.1002/ijgo.13879 \u003c/li\u003e\n\u003cli\u003eMa Z, Richardson LC. Cancer screening prevalence and associated factors among US adults. Preventing Chronic Disease. 2022; 19:E22. https://doi.org/10.5888/pcd19.220063 \u003c/li\u003e\n\u003cli\u003eBoguradzka A, Wiszniewski M, Kaminski MF, Kraszewska E, Mazurczak-Pluta T, Rzewuska D, Ptasinski A, Regula J. The effect of primary care physician counseling on participation rate and use of sedation in colonoscopy-based colorectal cancer screening program\u0026ndash;a randomized controlled study. Scand J Gastroenterol. 2014;49(7):878\u0026ndash;84. https://doi.org/10.3109/00365521.2014.913191.\u003c/li\u003e\n\u003cli\u003eMazzone PJ, Tenenbaum A, Seeley M, Petersen H, Lyon C, Han X, Wang XF. Impact of a Lung Cancer Screening Counseling and Shared decision-making visit. Chest. 2017;151(3):572\u0026ndash;8. https://doi.org/10.1016/j.chest.2016.10.027. \u003c/li\u003e\n\u003cli\u003eLinfield DT, Rothberg MB, Pfoh ER, Noss R, Cassard L, Powers JC, Lipold L, Martinez KA. Primary care physician referral practices regarding BRCA1/2 genetic counseling in a major health system. Breast Cancer Res Treat. 2022;195(2):153\u0026ndash;60. https://doi.org/10.1007/s10549-022-06523-5.\u003c/li\u003e\n\u003cli\u003eSudharshini S, Anantharaman V, Chitra A. A cross-sectional study on knowledge, attitude, and practice on cervical cancer and screening among female health care workers of Chennai Corporation. Journal of Academy of Medical Sciences. 2012; 2(4), 124\u0026ndash;128. https://doi.org/10.1177/17455065211017066\u003c/li\u003e\n\u003cli\u003eBehery MB, Bahbah AA, Mohamed Shawqi M, et al. Knowledge, attitude, and practice towards uterine cervical cancer screening in Egyptian females: a nationwide cross-sectional study. BMC Cancer. 2025;25(1):237. Published 2025 Feb 11. https://doi.org/ 10.1186/s12885-025-13530-4\u003c/li\u003e\n\u003cli\u003eMakhubo MT, Naidoo TD. Healthcare worker compliance with cervical cancer screening guidelines: An audit at district and regional level of care in the Pietermaritzburg Metropolitan area of KwaZulu-Natal. Southern African Journal of HIV Medicine. 2020; 21(1), 1\u0026ndash;6. https://doi.org/10.4102/sajhivmed.v21i1.1088\u003c/li\u003e\n\u003cli\u003eIBM Corp. IBM SPSS Statistics for Windows. Version 28. (2021) IBM Corp., Armonk.\u003c/li\u003e\n\u003cli\u003eDe Abreu C, Horsfall H, Learmonth D. Adherence barriers and facilitators for cervical screening amongst currently disadvantaged women in the greater Cape Town region of South Africa. Afr J Prim Health Care Fam Med. 2013;5(1):492. Published 2013. https://doi.org/ 10.4102/phcfm.v5i1.492\u003c/li\u003e\n\u003cli\u003eCatherine M Kress, Lisa Sharling, Ashli A Owen-Smith, Dawit Desalegn, Henry M Blumberg \u0026amp; Jennifer Goedken. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers, International Journal of Women\u0026apos;s Health. 2015; 765-772, https://doi.org/ 10.2147/ijwh.s85138\u003c/li\u003e\n\u003cli\u003eMittal H, Gupta PK, Kachroo N, Sinha R, Goyal N. Knowledge, attitude, and practice towards cervical cancer among health care workers of Uttarakhand. Int J Acad Med Pharm 2024; 6 (1); 1004-1010 https://doi.org/10.47009/jamp.2024.6.1.199\u003c/li\u003e\n\u003cli\u003eEaswaran V, Shorog EM, Alshahrani AA, Mohammad AAS, Sadiq MMJ, Alavudeen SS, Khan NA, Akhtar MS, Almeleebia TM, Alshahrani SM. Knowledge, Attitudes, and Practices Related to Cervical Cancer Prevention and Screening among Female Pharmacy Students at a Public University in a Southern Region of Saudi Arabia. Healthcare. 2023; 11(20):2798. https://doi.org/10.3390/healthcare11202798\u003c/li\u003e\n\u003cli\u003eLiebermann E, Sego R, Vieira D, Cheng Q, Xu B, Arome M, Azevedo A, Ginsburg O, So WKW. Roles and activities of nurses in cancer prevention and early detection in low- and middle-income countries: A scoping review. Asia Pac J Oncol Nurs. 2023;10(7):100242. https://doi.org/ 10.1016/j.apjon.2023.100242. \u003c/li\u003e\n\u003cli\u003eKress C, Sharling L, Owen-smith A, Desalegn D, Blumberg M, Goedken J. Knowledge, attitudes, and practices regarding cervical cancer and screening among Ethiopian health care workers. International Journal of Women\u0026apos;s Health, 2015: 7: 765\u0026ndash;772. https://doi.org/ 10.2147/IJWH.S85138. \u003c/li\u003e\n\u003cli\u003eKieti S. Knowledge, attitude and practices on cervical cancer screening and prevention methods among nurses at two Nairobi hospitals in Kenya, submitted in accordance with the requirements for the degree of Master of Arts in nursing science at the university of south Africa, 2016. p:41. http://hdl.handle.net/10500/22760\u003c/li\u003e\n\u003cli\u003eNational Cancer Institute. Cervical Cancer Screening - NCI (2025). Available from: https://www.cancer.gov/types/cervical/screening. Accessed 18 April 2025\u003c/li\u003e\n\u003cli\u003eBray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin. 2018 Nov;68(6):394-424. https://doi.org/10.3322/caac.21492. \u003c/li\u003e\n\u003cli\u003eSalvatore Vaccarella, Silvia Franceschi, David Zaridze, Mario Poljak, Piret Veerus, Martyn Plummer, Freddie Bray. Preventable fractions of cervical cancer via effective screening in six Baltic, central, and eastern European countries 2017-40: a population-based study. \u003cem\u003eLancet Oncol.\u003c/em\u003e 2016; 17(10):1445-1452. https://doi.org/10.1016/S1470-2045(16)30275-3.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-the-egyptian-public-health-association","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jepa","sideBox":"Learn more about [Journal of the Egyptian Public Health Association](http://jepha.springeropen.com)","snPcode":"42506","submissionUrl":"https://submission.nature.com/new-submission/42506/3","title":"Journal of the Egyptian Public Health Association","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthcare Workers, Compliance, Cervical Cancer, Screening, Guidelines","lastPublishedDoi":"10.21203/rs.3.rs-7186684/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7186684/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCervical cancer has a massive impact worldwide and is ranked as the 13th most frequent cancer among women in Egypt. It can be successfully treated if it is detected early by regular screening. This study aimed to assess the level of knowledge of healthcare workers regarding cervical cancer screening guidelines and to check the degree of their compliance with those guidelines.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003e A cross-sectional study was conducted among 83 healthcare workers (including physicians and professional nurses) at the Obstetrics and Gynaecology department, Zagazig University Hospitals, using a structured questionnaire assessing knowledge, attitude regarding cervical cancer screening guidelines and evaluating barriers and facilitators to compliance with screening guidelines.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe mean knowledge score of the participants was 65.06\u0026thinsp;\u0026plusmn;\u0026thinsp;22.41, and the median 75% ranging from 50% to 75%. The mean attitude score of the participants was 22.71\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6, and the median 23% ranging from 21% to 24%. Lack of awareness was reported by 63.9% to be the main barrier to compliance, while support from management was reported by 80.7% to be the facilitator to compliance with cervical cancer screening guidelines. There was a statistically significant relation between total attitude score and profession (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) and a statistically significant relation between total knowledge score and years of experience (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003e Although a wide agreement of recognition of the importance of cervical cancer screening is present, still existing shortage in knowledge and barriers to compliance with guidelines. This highlights the importance of enhancing the knowledge and clarification of cervical cancer screening guidelines among healthcare workers.\u003c/p\u003e","manuscriptTitle":"Healthcare workers` Compliance with Cervical Cancer Screening Guidelines: Cross-Sectional Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-29 04:11:19","doi":"10.21203/rs.3.rs-7186684/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2025-11-23T02:42:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-11T12:42:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190897384671296075253772858751060736564","date":"2025-11-08T09:27:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287033184229578991093152399384874862996","date":"2025-10-15T12:27:10+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-14T12:26:14+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-13T23:04:42+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-08T05:09:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of the Egyptian Public Health Association","date":"2025-10-06T19:28:25+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-the-egyptian-public-health-association","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jepa","sideBox":"Learn more about [Journal of the Egyptian Public Health Association](http://jepha.springeropen.com)","snPcode":"42506","submissionUrl":"https://submission.nature.com/new-submission/42506/3","title":"Journal of the Egyptian Public Health Association","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"4c0fe813-574e-4454-b20f-4181cb006f16","owner":[],"postedDate":"October 29th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-10-29T04:11:19+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-29 04:11:19","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7186684","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7186684","identity":"rs-7186684","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}