Evaluation of Cervical Cancer Screening Uptake and Risk Factors Knowledge: Health Beliefs Model (HBM)

Introduction

Cervical cancer (CC) is responsible for 230,200 deaths and 444,500 cases of disease annually among women in the developing country [1, 2]. The mortality rates for CC are expected to increase by 25 % during the next decade, despite the fact that this is one of the most preventable cancers. In resource-limited countries access to cervical cancer screening (CCS) and vaccination is poor [3]. In sub- Saharan Africa over 80% of CC is detected in late stages [3, 4]. There is low survival rate when women had cervical cancer at an advanced stage of disease [5, 6].

In Ethiopia, CC is the second most frequent female cancer with incidence rate (16.3%) among women between 15 and 44 years of age next to breast cancer (29.6%) [7]. Ethiopia has 29.4 million women aged 15 years and older and 7.095 women are reported with CC of whom 4,732 die from the disease [7].

Currently in Ethiopia, 200 health facilities are providing VIA screening and cryotherapy treatment and more than 52,000 women were screened in 2016/17. In addition, Loop Electrical Excision Procedure (LEEP) service was scaled up from five to fifteen hospitals. The Federal Ministry of Health (FMoH) is working to scale up Visual Inspection with Acetic Acid (VIA) screening and cryotherapy treatment into 823 districts [8]. Even though 20 million women are eligible for cervical screening in Ethiopia only less than 1% has been screened [8].

Infection with high-risk human papillomavirus (HR HPV) is the cause of almost all CC cases. Early sexual debut, multiple sexual partners, young age at first delivery, multi-parity, immunosuppression, co-infection with other sexually transmitted infections (STIs), cigarette smoking, long-term use of hormonal contraceptives, estrogen-only hormone replacement therapy and obesity are some of the factors that has been associated with an increased risk of developing CC [9].

Appropriate level of knowledge, attitude, and beliefs are key elements for adopting healthy lifestyle, influencing human behaviors, accepting newly introduced preventive measures and determining the stage at which cancer patient presents to health facility [10].

Studies from many parts of the world including Ethiopia have shown lack of awareness within populations regarding CC symptoms, early signs, and the role of screening and HPV vaccination for prevention [11, 12, 13, 14, 15, 16, 17]. Cervical cancer’s long latency and recognizable pre- cancerous lesions make screening a particularly effective way of prevention as these pre-cancerous lesions, once identified, can be expectantly managed or treated safely and inexpensively in an outpatient setting [13]. It is important to create awareness among communities through educational programs on cancer prevention, preventable risk factors, benefits of early diagnosis, and availability of screening facilities. In the developed countries, CC screening programs have reduced the incidence of invasive lesions up to 80% [12].

Methodology

The goal of this study was to investigate health beliefs on uptake of cervical cancer screening and treatments program and knowledge on cervical cancer risk factors in Adama, Oromiya, Ethiopia. A cross-sectional 412 women participated in this study between September to December 2017 at SAMH. The only inclusion criteria were participants had some level of knowledge and awareness about cervical cancer disease.

The study was conducted in Adama Town, Oromia region, having a total population of 1.356.342 of whom 659.992 are female. As the population of East Shewa also seeks medical care in Adama, this population was also part of the study population. The SAMH Hospital, which is located in Adama Town, is a private hospital with a history of cervical cancer screening programmes and is currently a center in which cervical cancer screening is performed.

Women who came for general medical checkup not primarily for cervical cancer screening were recruited update of cervical cancer and treatments, knowledge on risk factors were collected from all consenting women by standardized questionnaires.

Nurses who trained on interview questionnaires and had good experiences on cervical cancer interviewed the women in their native language, either Oromia or Amharic. The inclusion criteria were women between the ages of 20 and 70 years old.

The questionnaire was designed in English and translated into Oromifia and Amharic: the main language used in the study area and back translated to English with any discrepancies addressed was pretested among a group similar to the study respondents. The questionnaire had three sections. The first section included questions on the participants’ demographic characteristics such as age, education status, marital status, age at marriage, history of CC in her family, parity, household income and use of contraception. The study identified two outcomes i.e women visited health facility for CC purpose previously (1= visited, 0= not visited) and women who was underwent CCS (PAP or VIA) test (i.e. 1= Yes; 0= No).

The second section included nine questions that assessed the respondents’ specific risk factors knowledge about cervical cancer prevention. Questions are required “Yes” or “No” responses. The risk factors included unprotected sex, multiple sexual partnerships, smoking, use of contraception, previous exposure to sexually transmitted diseases and early sex onset.

The third section examined women’s health beliefs towards cervical cancer screening. The HBM is a well- known health education model that is simple in design and that has been used successfully in health The HBM focuses on five determinants: Perceived susceptibility, Perceived severity, perceived benefits [Positive attributes of the action], and perceived barriers [Negative attributes of the action], and cues for action.

interventions. The questionnaire was developed based on the HBM theory to assess beliefs related to cervical cancer screening [18, 19]. Based on literature reviews on factors influencing screening practice, 71 items were identified and grouped into the five domains of the HBM and checked for clarity and pilot questionnaires were used and corrected accordingly. All items were translated into Oromia and Amharic language since the majority of participants was from Oromia. Dichotomous responses i.e. Yes or No were used.

The ethical committee of the College of Natural Sciences, Addis Ababa University has examined the

Statistical analysis was performed using the SPSS version 20 software. Means and standard deviations were used to describe continuous variables. An association was statistically significant if the p-value was less than or socio-demographic characteristics, health beliefs and risk factors knowledge about cervical cancer prevention.

A binary outcome of risk factors knowledge was determined and women who had answered “yes” response were considered to be more correctly responded while those who said “no” were considered to have no knowledge.

Results

A total of 412 women participated in the study and those who had some level of knowledge and awareness about cervical cancer disease were included in this study. The mean age of women was 44.6 years (SD=9.3). Two hundred forty seven women (59.9%) and 18.7% (77/412) women were under grade 10 and above certificate, respectively (Table 1).

One hundred ninety three women (46.8%) were married; 11.4% were living with partners and 15.8% (65/412) was never married. Women who had married below age of 20 years were 73.5% (303/412) and rest was married at the age of 21 and older. Relatively higher number of women was used modern medicine of 69.4% (286/412) as compared to traditional treatment, 30.6% (126/412) (Table 1).

More than three-fourth of women 78.6% (324/412) were responded that no history of cervical cancer in their families was known and 3.2% (13/412) reported that there was a cervical cancer family history documented. A total of 356/412 (86.2%) women had children less than three. Almost half of women had household income less than ETB1500 per month and only 3.6% had monthly income greater than ETB 5000. Women, 34.5% (142/412), were used contraception drug or device in their life time (Table 1).

A total of 6.8% (28/412) women reported that they had visited health facility for purpose of getting cervical cancer service. Accordingly from women who had visited health facility, only 3.2% (13/412), had undergone cervical screening either of VIA or Pap test (Table 1).

Table 2 shows that a quarter of women (25.2%) didn’t give correct answer on risk factors knowledge for cervical cancer. A percentage of 41.4 and 38.3 of women aware that risk factors of having more children and not regularly checked for VIA or PAP screening test could be a likely risk factors.

Women were aware that, 11.2%, early sexual debut was associated with development of CC and 59.2% recognized smoking cigarettes as a risk factor. Use of birth control pill for a longer time was recognized as a risk factor by 56.4%, and multiple births by 41.4% of women (Table 2). On average (ẋ=5.6) women correctly identified out of the nine risk factors presented in this study.

A total of 6.8% (28/412) participants had visited CCHF previously at least once for cervical cancer checkup (table 1). There was a significant association between women who had graduated at least certificate level and who had visited CCHF (p value =0.048). A significant association was also found between women who had cervical cancer history in their family and previous visit of cervical cancer health facility for checkup purpose (p value =0.000).

Moreover, women’s household income that had more than ETB 1500 was significantly associated with a previous visit to a cervical cancer health facility for checkup condition (p value=0.000). From total of 28 women who had visited CCHF, 46.42% (13/28) participants underwent VIA or PAP screening test (p value =0.000). Almost, 70% of participants with a history of CC in the family (9/13) had visited a CC health facility. Variables like marital status, number of children, age, age at first marriage and type of treatment were not statistical associated with women visit for any kind cervical cancer service.

Discussion

In this study all women had heard at least some level about cervical cancer through different sources in previous time that used as inclusion criteria for health belief model. This might be explained by the fact that the FMOH has given awareness training for patient and health care professionals to implement interventions for reducing the incidence of cervical cancer in the Ethiopia population [8]. In this study the cervical cancer coverage was 3.2% that is higher than national cervical cancer screening coverage rate [8] and that also was supported by other study Bruni L, et al. [20].

The author concluded that health behavior is a personal`s beliefs rather than objective reality and therefore women health beliefs is crucial step for promoting cervical cancer screening uptake service [19]. Difference were observed in women age averagely that explained young and old women included in this study and could be seen as a good representative sample [21]. Study done by Author Wassie S, et al. [22] in Ethiopia revealed that 70% of participants didn’t agree the effectiveness of traditional medicine that was confirmed also in this study i.e. women were preferred modern medicine for cervical cancer treatment.

Those women knew about cervical cancer disease through their family members, certificate level education and better household income were visited the health facility for the purpose of screening similar findings to our study done previously in Ethiopia [16, 23, 24, 25]. This is might be concluded as women have inadequate knowledge about prevention and cervical cancer they are not likely to present for screening.

This study revealed women recognized smoking cigarettes, multiple births started sex at earlier age and use of birth control longer were identified as risk factors for cervical cancer disease and these were supported by Mukama, et al. [26]. Although most women identified most risk factors correctly above mean, the perceived susceptibility, severe and barriers influenced usage of cervical cancer screening service that contributed for low coverage cervical cancer screening as indicated by author Chantelle, et al. [27].

Women in this study believed that a cervical cancer screening test needs when they had symptoms; sex with many partner and contraceptive drug and were agreed that getting a CCS test allows for early detection of cervical cancer [28]. However, in sub-Saharan Africa over 80% of CC is detected in late stages of CC [3, 4].

In this study women were concluded that they were not comfortable if the doctor was man and not likely to be screened and if the clinic hadn’t a program of “see and treat” approach. Women were visited health facilities when they had pain in her genitals and heard about cervical cancer in any media and/or through her doctors or nurses.

One of misconception identified in this study was women concluded that douching every day could be seen as a guarantee for not to take cervical cancer screening test. Study done in USA revealed that vaginal douching is generally viewed as a practice enhancing vaginal hygiene and women believe that it can protect against sexually transmitted disease; however contradictory to these douching increase risk of having HPV of any type [29].

Previous information in Ethiopia revealed that the cervical cancer screening coverage was less than 1% [8] which not supported by this study where 3.2% of higher uptake of cervical cancer screening service found that may be participants` recall bias or small size study population and may not be a good representative data [30]. Our findings were also similar with world Health Organization reported that only 19% screening coverage in developing countries [31].

In our study only 3.2% participants were visited health facility for purpose of cervical cancer screening service whereas study from Southern part of Ethiopia found that more than one thirds of the respondents mentioned visual inspection with acetic acid as a screening method and 11.4% of the respondents were screened for cervical cancer [17]. This may explained due to various reasons like individual beliefs and cultural difference among study groups.

The author summarized that women`s belief about cervical cancer was influenced by the culture, knowledge, social background, and the experience of health/illness [10, 32]. Women beliefs that they can monitor their health situation if they pre-aware of it and information available about the disease [32]. This author is summarized that various perception beliefs identified and necessary corrective action has to design respective to different culture and social groups [33]. Thus, it is important to consider individual differences, because people may have different combinations of health beliefs [34].

Overall Ethiopia may need structured awareness, educational program and screening use to address different level of individual barrier, susceptibility and severity [35, 36]. A continue and uninterrupted individual beliefs changing program may be necessary at all level since changing people`s beliefs is difficult than changing social and economical factors of community. Therefore, changing social structure and living condition of people may improve women health through increasing preventive belief and incentives for screening tests [18].

Free cervical cancer screening tests may not be the last resort rather attention need to educate women to change their perceived susceptibility, severity and barrier through various ways and integrated health belief model may be helpful [37].

To explore the relationship between health beliefs and women health behaviors the conceptual model of health belief model is used to study factors influencing Ethiopian women’s participation in cervical cancer screening and may be considered in designing culturally appropriate cervical cancer screening interventions. This model is significantly identified that work has to do to change the women`s expectation of disease susceptibility and severity where low number of women considered themselves susceptible to a cervical cancer disease and its severe consequence. Due to lack of information, reminder through media or personal influence and individual beliefs, women didn’t test the benefits of taking any preventive action [30, 38, 39, 40].

Ethiopia is prepared to launch HPV vaccine for women aged at 14 that is a big opportunity for prevention cervical cancer and increase awareness among population where consider as a game changing phenomena.

The limitation of this study was a cross-sectional study that was not possible to link the relationship between belief, cervical cancer risk factor, and screening tests rate. Ideally, a prospective study must be conducted to analyze the relationships between beliefs measured and the screening test as an outcome.

Conclusion

The health belief model could be used to study factors influencing Ethiopian women’s participation in cervical cancer screening and may be considered in designing culturally appropriate cervical cancer screening interventions.

Conflicts of Interest

Funding: No funding sources and this research did not receive any specific fund from funding agencies in the public, commercial, or not-for-profit sectors.

Acknowledgement: The authors would like to thank all participants of this study and staffs of SAMH in data collection.