Althought pap smear screening in Malaysia began in the late 1960s, there was no decline in number

of incidence of cervical cancer in Malaysia. (Kannan, 2017).

 Nor Akma et al. (2018) documented that the rate of non-adherence to Pap smear screening
among Malaysian women was very high.

There are several factors that contribute to the reluctancy of women to do pap smear screening in
Malaysia.

 A study by Abd Nazer Ali (2018) revealed that people aware in which cervical cancer affects
only female & HPV vaccination can helps reduce the incidence, but they did not know the
common age related to cervical cancer, the prognosis and the growth rate of cervical cancer.

 One of them are lack knowledge and awareness of pap smear screening which is pap smear test
among malaysian. This statement is supported by a study from Wong et al. (2008) study which
indicates, poor knowledge regarding the natural history, the effectiveness of screening and risk
factors of cervical cancer may have contributed to women’s non-participation during Pap smear
screening.

 A journal from Tongtong Liu (2017) also stated that lack of knowledge regarding cervical cancer
screening are due to inadequate health education, restricted opportunity to gain knowledge,
cultural barriers and difficulty to convey information especially towards rural womens.

 In Sakineh et al. (2008) study, lack of health practitioner’s recommendation and poor knowledge
about Pap smear were the common reason for non-involvement towards Pap smear.

 An article from Maznah Dahlui (2013) stated that only women that gain information about
cervical cancer most likely to do pap smear test and the common source of information is from
healthcare personnel, mass media and brochures.

 According to the study by Redhwan (2012), most of the participants get their information
regarding pap smear test is from health care provider followed by printed media, electronic
media and workplace.

 According to study by Siti et al (2011), most of the study respondents still have limited
knowledge and did not know the significance of pap smear although they have heard and knew
about pap smear test before.

 Based on research by Shobeiri et all (2016), lack of knowledge about cervical cancer can affect
women decision to accept Pap smear screening. She also stated that educational levels play an
important role that prevents women from using the screening services. Participant who had
lower educational level and lower household income had less tendencies to do Pap smear.

 As a comparison to those with lower education, women who attained tertiary education level
were more likely to perceive working commitment as a barrier for undergoing Pap smear. (Nik
Nairan et al., 2017)

Next factors that contribute to low number of women participating in pap smear test is the attitude.

Women’s attitude or belief regarding the pap smear test would affect the preventive measures of
cervical cancer.

 The common perceived barriers among women who either did not undergo Pap smear or had it
more than three years ago were worry, pain and embarrassment as reported by Nik Nairan et al.
 (2017). Nik Nairan et al. (2017) also documented that worry being the most common perceived
barriers among women.

 A study by Zaridah S (2014) stated that the main causes of women not performing a pap smear
test is lack of knowledge and awareness, feels embarrassed to expose body parts and also cost
of the test. Other reasons may be associated with place of screening, lack of time, inadequate
female doctor and issue with virginity.

 The survey was done by Zaridah (2014) on 221 cervical cancer patients within aged of 25-85
years old at 8 healthcare centers. ”. Majority of the patients were never done Pap smear before
and not done it within past 3 years. There were several reasons for not having Pap smear such as
“Never heard about it”, “Shy”, “Afraid to do it”, “Think the test is not important” and “No
encouragement from family”.

 A study by Lemson and Khin (2018), the perception by university female students who came
from Asian countries on cervical cancer screening are mostly neutral compared to greater due to
the fact of the body part exposure especially to male doctor during the examination is against
religious and cultural belief.

 An article from Yitagesu (2017) stated that factors that influence the decision of women to not
doing pap smear test is due to lack of information regarding the risk factors of cervical cancer,
their beliefs on the disease and restricted access to healthcare services.

 A study from L.P.Wong (2008) reveals that women refuse to do pap smear test because they
thought that it is unnecessary since they did not have any risk factors of developing cervical
cancer such as abnormal vaginal discharge and promiscuity.

 Based on study by Sawitree Visanuyothin et al. (2015), married women who are housewives, and
living with their spouses have more awareness regarding the consequences of cervical cancer
and have less embarrassment and fear about undergoing a Pap smear test

 According to Hassani et all (2017), one of the barrier of Pap smear test that influenced women
was the negative experiences of first Pap test. These were including fear of getting result of first
test and readiness condition for getting first test. The readiness of the participants was also
influenced by participation of husband or family member in teaching session. Other factors such
as personal barrier that including embrassment of getting the test. Some of the women also
unsatisfied with the services given by unskillful healthcare practitioner.

 According to a study done by Nuurain et al (2017), in comparing to the woman who did not
received her husband’s support on Pap smear, a woman who received husband’s support on Pap
smear is more likely to do Pap smear.

------- that also play a part in affecting women’s participation in pap smear is ----------

 A study by Nuurain et al (2017) shows that the woman who annually do medical check-up have
higher tendency to practice pap smear compared to the woman who do not do.