DOI:10.31557/APJCP.2021.22.1.

69
Cervical Cancer Knowledge

RESEARCH ARTICLE Editorial Process: Submission:06/03/2020 Acceptance:01/08/2021

Development and Validation of Questionnaire to Assess

Knowledge about Cervical Cancer among Women Aged 20 to
65 years in Oman
Aisha Al Saadi*
Abstract
Objective: This study aimed to develop and validate a questionnaire to assess awareness of cervical cancer, its risk
factors, and methods of prevention among Arabic-speaking women aged 20 years and over. Methods: The study took
place at primary healthcare institutions, Al Buraimi Governorate, Oman, between November 2018 to February 2019.
In phase I, seventy items concerning cervical cancer and its prevention were generated through a literature review. In
phase 2, the questionnaire was validated through calculating the content validity index (CVI) for both item level (I-CVI)
and the scale level (S-CVI), in this phase a shortened English questionnaire of 55 items was formed, then rigorously
translated to the Arabic language in phase III. The questionnaire was tested for reliability in two stages: A pilot and
a large field test in phase IV. Results: A total of 55 out of 70 items formed the final version of the questionnaire. The
final instrument had an S-CVI/Ave of 0.92. The questionnaire called the Knowledge in Cervical Cancer and Prevention
Methods 55-items (KCCPM-55). The Cronbach alpha coefficient was 0.940 for the whole questionnaire, and ranged
between 0.57 to 0.93 for each of the domains. Test-retest reliability was examined in a subsample of the total participants
sample (r = 0.769, p < 0.001). Conclusion: The KCCPM-55 has been successfully developed in the Arabic language and
found to be a valid and reliable instrument for assessing the level of knowledge about cervical cancer and prevention
methods among women aged 20 to 65 years in Oman.

Keywords: Knowledge- cervical cancer- cancer prevention- women- questionnaire validation

Asian Pac J Cancer Prev, 22 (1), 69-74

Introduction a crude incidence rate of 4.7 and a mortality rate of 2.5

respectively ( Bruni et al.,2019).
Cervical cancer is a major public health problem for Cervical cancer is mostly caused by the infection of
adult women. The incidence varies greatly worldwide. Human Papilloma Virus (HPV) (Tezcan et al., 2014). This
It continues to represent the fourth most common virus has been implicated in 90% of cases of cervical
malignancy affecting women all over the world, and the squamous cell cancer (Daniyal et al., 2015). HPV 16 and
second most common cancer in developing areas with an HPV 18 types of the virus cause approximately 70% of all
estimated 570,000 new cases and 311,000 deaths from the cervical cancer cases (Tewari and Monk, 2012). Recent
disease occurred in 2018; more than 80% of the new cases study found the prevalence of Human Papilloma Virus in
and deaths occurring in low and middle-income countries Oman is 17.8% (Al-Lawati et al., 2020).
(Arbyn et al., 2019; World Health Organization, 2020). Cervical cancer is fatal if untreated but preventable
The predictions in the Middle East, indicate that this region with the aid of primary and secondary prevention methods.
will experience an increase of mortality incidence which In countries where the resources exist, many primary and
will approximately reach 181% over the next 15 years secondary preventative approaches have been optimized to
(Dey and Soliman, 2010), which means that the global ensure cervical cancer prevention. Secondary prevention
burden occurs in developing areas. is based on cervical screening. The Papanicolaou (Pap)
The incidence of cancer is rapidly increasing in Oman test is the most widely used cervical cancer screening
(Al-Lawati et al., 2008). Current estimates of incidence test. It used for screening 80% of women with cervical
and mortality indicate that every year 77 women are cancer. The primary prevention is based on prophylactic
diagnosed with cervical cancer and 41 die from the vaccination against the major cause of cervical cancer,
disease. Cervical cancer ranks as the 3rd most frequent the carcinogenic human papillomavirus types 16 and
cancer among women aged 15 to 44 years in Oman with 18. However, the burden of cervical cancer is very high

Department of Studies and Research, Directorate General of Planning and Studies, Ministry of Health, Muscat, Oman.
*For Correspondence: Challenger.777@hotmail.com
Asian Pacific Journal of Cancer Prevention, Vol 22 69
Aisha Al Saadi

(Daniyal et al., 2015), because the governmental effort Phase 1: Item generation
to inform the population about cervical cancer is still A literature search for studies discussing the issues
lacking. A very poor level of knowledge about cervical concerning cervical cancer and its prevention was
cancer is evident among general populations, as well as conducted before designing the questionnaire. After
health professionals (Giles and Garland, 2006; Ortashi a thorough literature review, the following four main
et al., 2013). Implementing both methods of prevention domains of knowledge were generated: 1) general
can reduce the death rate from cervical cancer, however, knowledge about cervical cancer; 2) risk factors
it cannot be attained without improving community associated with the disease; 3) knowledge about primary
awareness of this disease which improve early recognition prevention; 4) Knowledge about secondary prevention.
and prompt treatment (Sankaranarayanan and Ferlay, Many validated tools that cover a wider spectrum of
2005). knowledge assessment relating to cervical cancer were
In Oman, no screening program yet instituted at also reviewed (Donders et al.,2007; Jaglarz et al., 2014;
primary health care which invites high-risk women for Onan et al.,2009). The first version of the questionnaire
regular cytological screening. The HPV vaccine is also included 10-15 items about each domain, depending on
not yet introduced in the national immunization program. how relevant the items seemed. A list of 70 items was
Prophylaxis and early detection services play a vital role. generated from the literature review.
However, the uptake of those services will remain low with
a lack of awareness about cervical cancer. The assessment Phase 2: Construction and Validity of the questionnaire
of knowledge with a valid and reliable instrument is the The scale was developed with 70 items. A panel of 8
first step in creating interventions to raise knowledge and content experts (four academicians and four practitioners)
increase the uptake of cervical cancer screening services. experience in the area of gynecology were asked to
Therefore, this study aims to develop and validate a evaluate the scale in two rounds. Their expert judgment
questionnaire used to assess women’s knowledge about on the relevancy of each item to the corresponding
cervical cancer, its risk factors, and prevention methods. domain was requested in the first round , using a 4-point
Assessing the level of knowledge at a younger age is content validity index (CVI) (1, not relevant, 2, Somewhat
imperative because of the relatively lower marriage relevant, 3, quite relevant 4, highly relevant) (Davis,
and childbirth ages in Oman (Islam et al., 2013). The 1992). All domains of questionnaire were defined ( Table
availability of an Arabic questionnaire that widely assesses 1). The experts were requested to critically review each
the knowledge related to cervical cancer might help to domain and provide score on each item independently.
improve the way we fight this preventable malignancy Their assessment of translation and clarity of items were
by having a more comprehensive overview of the level also requested in the second round. This has resulted in
of knowledge among the women population. refining the questionnaire domains and its items.
Content validity index was calculated both for item
Materials and Methods level (I-CVI) and the scale level (S-CVI) .Content validity
index at item level (I-CVI) was calculated by totaling the
The method followed used the basic principles for number of experts giving a rating of 3 or 4 for each item
questionnaire development suggested by the European divided by the total number of experts ( Polit et al. 2007).
Organization for Research and Treatment of Cancer The CVI cut-off point was set at 0-78 (Lynn 1986). The
(EORTC) Quality of Life Group guidelines (Johnson et items that had CVI ≥ 0.78 were considered as relevant,
al., 2011). This method has been successfully applied and items below 0.78 were eliminated. Based on item
by Jaglarz et al., (2014) to create the Cervical-Cancer- relevance the number of items decreased from 70 to
Knowledge-Prevention-64 questionnaire used for 55. Average approach was used to compute the content
assessing the level of knowledge about cervical cancer validity of the overall scale S-CVI/Ave . The index of
among school girls and female students in Poland. The average congruity was judged according to the standard
current study followed the same process for questionnaire which is advised by Waltz et al., (2005).
development, however, the questionnaire is initially The final tool consists of 55 items (4 concerning
constructed in the English language based on the reviewed demographic data), and the remaining 51 items were
literature and then translated and tested in the Arabic divided into four main domains, namely general
language. knowledge about cervical cancer ( 6 items), knowledge
The questionnaire was developed in four phases: about risk factors associated with the disease (17 items),
1) item generation; 2) construction and validity of the knowledge about primary prevention with subdomains:
questionnaire; 3) translation of the questionnaire; 4) 1) lifestyle (8 items); HPV vaccine (7 items) and
field testing. A panel of content experts were requested knowledge about secondary prevention with subdomains:
to assessed the content validity of questionnaire in a 1) symptoms of cervical cancer ( 9 items); 2) cytological
two-round evaluation before conducting the field test. The screening (3 items).
study was approved by a Research Ethical Review and
Approval Committee (RERAC) at the Ministry of Health. Phase 3: Translation of the questionnaire
The questionnaire was accompanied by a consent form The current study followed similar translation and
and a cover letter explaining the purpose of the study and adaptation process implemented by Alanazi et al.,
respondents’ anonymity and voluntariness. (2017) for adapting the hospital consumer assessment of
healthcare providers and system (HCAHPS) questionnaire
70 Asian Pacific Journal of Cancer Prevention, Vol 22
 DOI:10.31557/APJCP.2021.22.1.69
Cervical Cancer Knowledge
in the Arabic context (Figure 1). The translation was study, and women who do not have cervical cancer, thus,
accomplished by following the four-step translation women who are diagnosed with cervical cancer and/or
framework: (1) translation of English version into Arabic receiving cancer treatment were excluded from the study.
by a qualified bilingual translator: (2) The Arabic version The self-administered questionnaires were distributed
was translated back to English and then reviewed by the to the participants through the nurse in-charge in each
panel of content experts in the second round to ensure that primary healthcare centers. The completed questionnaires
the translation did not change the meaning of the content and signed consent forms were inserted in two separate
(content equivalence): (3) both the Arabic and English boxes placed at the head of the department office. Data
versions were given to a qualified bilingual translator were coded and entered into a computer using two of the
for linguistic validation and identify the similarities latest versions of prepared packages of statistical analysis
and differences between the two versions (semantic namely Statistical Package for Social Sciences (SPSS)
equivalence). In this step, the discrepancies between the version 25.0 for Windows and Minitab version 18.1. All
two versions were assessed, to ensure both versions are these programs used in different stages of data processing
identical in content and meaning (conceptual equivalence) to process the raw data obtained from the questionnaires.
using the bilingual translation method. Some questions The researcher used descriptive statistics to describe
touched an important subject of women’s sexuality; the participants’ characteristics, scores of cervical cancer’s
therefore, the appropriateness of wording and potential general knowledge, risk factors, knowledge of primary
misinterpretation was considered to achieve the final item and secondary prevention. Internal consistency reliability
wording of the questionnaire (cultural validation). was assessed by computing Cronbach’s alpha and Kuder
-Richardson 20. Test-retest reliability was examined in a
Phase 4: Field Testing of the questionnaire subsample of the total participant sample by computing
Psychometric properties were initially assessed the Pearson correlation coefficients.
by a pilot study in June 2018. A sample of 70 Omani
women attending Al Buraimi hospital were randomly Results
and voluntarily enrolled in the study. The researcher
was available to explain to participants the types of The Scale-level content validity score was calculated
questions included in the questionnaire and to ensure that by using averaging approach (Polit and Beck, 2006).
participants understood all sections of the questionnaire, The S-CVI/Ave was calculated by first multiplying the
particularly the section which ranks the relation between number of experts by the number of items which returns
the identified risk factors and the occurrence of cervical the total number of possible item-by expert ratings is 560
cancer. Respondents were asked to rank the relation on ( 8 experts X 70items); 517 of them indicated relevance
a 6-item Likert scale [never=0, very little=1, little=2, (I-CVI ≥ 0.78). So the S-CVI/Ave was 517/560=0.92.
somewhat=3, much=4, and great=5]. The researcher The I-CVI for all the items ranged from 0.63 to
assessed the participants’ understanding of the answers 1. Based on item relevance, a total of 15 items were
they were choosing. The researcher also asked the considered as irrelevant (I-CVI < 0.78). The number of
participants about any words, phrases, or questions they items decreased from 70 to 55. The final version then
did not understand, or found unacceptable. All their translated to the Arabic language and then back into
comments were taken into consideration when forming English. The Arabic version was finally approved by
the final version of the scale. Data were analyzed for the panel of content experts in the second round. After
internal consistency. the content validation, the Arabic version was tested for
A large field survey was carried out between November reliability in two stages: the pilot and large field testing.
2018 to February 2019 in eight primary healthcare The results of Cronbach’s Alpha tests showed that the
centers in Al Buraimi governorate by using the newly alpha coefficient of the KCCPM-55 was 0.935 in the pilot
validated Arabic questionnaire, called KCCPM-55. A study with a range between 0.54 to 0.80 across the four
proportional sampling was carried out to collect data from domains of the scale, as presented in Table 2. Likewise,
approximately 5% of Omani women aged 20 to 65 years the alpha coefficient of the questionnaire in a larger sample
in Al Buraimi governorate. The sample proportionate showed almost the same results except the risk factor
to the number of women aged (20-65 years old) living domain showed remarkable improvement in internal
in the catchment area of the eight primary healthcare
institutions available in Al Buraimi governorate. The
total sample was 1000 participants, assuming a 95%
confidence level and a margin of error 3%. A website
size calculator was used “Raosoft” to calculate the study
size, then a proportional size approach was implemented
to calculate the size from each healthcare institution. A
woman attending the healthcare center for any reason at
the time of data collection were approached to participate
in the study if they meet the inclusion criteria: Omani
women who aged 20 years and over, women who can
read and write, to understand the consent form and fill the
questionnaire, women who consent to participate in the Figure 1. The Translation Process of KCCPM-55
Asian Pacific Journal of Cancer Prevention, Vol 22 71
Aisha Al Saadi

Table 1. Definitions of Proposed Domains of Cervical Cancer Knowledge

Domains Definition
General Knowledge about cervical cancer Knowledge about prevalence of disease, fatality, the causal role of infections in
cervical cancer, preventability of disease.
Risk factors associated with the disease Knowledge about the risk factors of cervical cancer.
Primary prevention Knowledge about two domains:
1-Life style factors that reduce the risk of cervical cancer.
2-Knowledge about Human Papillomavirus (HPV) vaccination.
Secondary prevention Knowledge about signs and symptoms of cervical cancer and knowledge about
screening based on the Pap test.

Table 2. Reliability Measures and Coefficients for 4 Sub-Scales of a Pilot (n=70) and Large Field Study (n=791)
Domains Measure A pilot study (n-70) Large field Study (n=791)
Coefficient Coefficient
General Knowledge about cervical cancer Cronbach’s Alpha 0.54 0.57
Knowledge about Risk factor and the occurrence of the disease Cronbach’s Alpha 0.70 0.93
Knowledge about primary prevention Cronbach’s Alpha 0.80 0.73
Knowledge about secondary prevention Kuder-Richardson 20 0.74 0.70
Overall value 0.935 0.94

consistency, it raised from 0.70 to 0.93. The Cronbach’s years at the time of the survey, followed by 310 (38.2%)
Alpha across the other three domains were as follows: were between 20 and 30 years old, and 93 (11.8%) of
0.57 for general knowledge about the disease; 0.73 for them were between 41 and 50 years. Only 1% (n=8) of
knowledge about primary prevention; 0.70 for secondary the women who participated in the survey were above
prevention (Table 2). A sample of 70 participants used 50 years of age. Concerning work status, the majority
to evaluate test-retest reliability. All completed the of the respondents were not working (n=442, 61.3%).
questionnaire again 2 weeks after their initial completion. More details on the demographic characteristics can be
Pearson coefficient for simple linear correlation found a found in Table 3.
significant relationship between the two cervical cancer
knowledge scores (r = 0.769, p < 0.001). Discussion
A total of 791 women (79.1%) were recruited to take
part in the large field study. Slightly less than a half of The content of the KCCPM-55 is the result of extensive
the respondents (48%, n= 380) were between 31 and 40 literature review and experts’ degree of agreement
regarding the content of the proposed instrument. The
Table 3. Sociodemographic Characteristics of scale was initially developed with 70 items and based on
Participants (N=791) item relevance, the number of items has decreased. A total
Characteristics n (%) of 55 items had CVI ≥ 0.78 which, based on Lynn ‘s
advice (1986), was considered as a relevant items. The
Age
final instrument had an S-CVI of 0.92. It is advised to
20-30 310 (39.2) determine a scale as having excellent content validity, it
31-40 380 (48.0) would contains a minimum I-CVI of 0.78 (Lynn 1986)
41-50 93 (11.8) and S-CVI/Ave of 0.90 or higher ( Waltz et al. 2005).
Above 50 8 (1) The KCCPM-55 has been successfully translated to the
Educational Level
Arabic context by following a model of a back-translation
process. This systematic procedure was needed to ensure
No education 5 (0.6)
the quality of translation outcomes. Results from the pilot
Primary 37 (4.7) study show that it is feasible to administer the Arabic
Secondary 327 (41.3) version of the KCCPM-55 questionnaire to a group of
Tertiary 422 (53.4) Omani women aged 20 years and over. All respondents
Marital Status found the questions acceptable and clear.
This study touched an important subject of women’s
Single 100 (12.7)
sexuality, however, the respondents did not reject taking
Married 663 (83.8) part in it, as the questionnaire is a self-administered
Other (divorced or widow) 28 (3.5) tool. Many self-administered and interview-based
Work status questionnaires were used in the Arabic speaking
Working 306 (38.7) population to assess knowledge about cervical cancer
(Al-Meer et al., 2011; Alsaad et al., 2012; Jassim et al.,
Not working 485 (61.3)

72 Asian Pacific Journal of Cancer Prevention, Vol 22

 DOI:10.31557/APJCP.2021.22.1.69
Cervical Cancer Knowledge
2018; Jradi andBawazi, 2019). All these studies focused The internal consistency and test-retest reliability for
on attitudes of women towards the Pap test. In contrast, the Arabic version was good. Although more research is
KCCPM-55 questionnaire is developed to assess a wider needed to strengthen the findings, preliminary findings
spectrum of knowledge relating to cervical cancer. The suggest that this tool would be a good instrument to
tool has focused not only on women knowledge about measure the change in knowledge after the educational
cytology screening, but also it evaluates women’s’ program.
knowledge about risk factors associated with the disease,
lifestyle factors affect a woman’s risk of cervical cancer, Acknowledgements
knowledge about the HPV vaccine, and knowledge about
symptoms of cervical cancer. Using this approach provides Statement conflict of Interest
a broad overview of the level of knowledge about cervical No conflict of interest.
cancer, which will contribute to supporting efforts to
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