Knowledge and Practices of Cervical Cancer among Married Men in Rural Phalombe?

Design

Across-sectional descriptive design was used to assess the knowledge and practices that men have about cervical cancer and screening. This design enabled the researcher to examine the relationship between cervical cancer and some variables of interest of the study participants.

Setting

The study was conducted in 6 villages of Chiopsya, Sakhome, Mariko, Nalingula 1, Chibwana and Sakwedwa in Phalombe District. Simple random sampling was used to select the villages and this was done manually. The names of all the villages were written on small pieces of paper. Then one piece of paper was picked at random without replacement. These villages are under Phalombe Health center catchment area. The facility has a catchment population of 42,477 and 19 villages. These sites were suitable for the study because Phalombe Health Centre offers cervical cancer screening for women in the district. The health facility has made strides in creating awareness as well as conducting cervical cancer screening compared to other health centers in the district. Therefore, Phalombe health center catchment area was chosen because it is more active in implementing cervical cancer interventions.

Recruitment

Systematic random sampling was used to recruit study participants where every kth participant was recruited. A list of households for each participating village was obtained from the Village head man with assistance from the Health Surveillance Assistant (HSAs). Participants were systematically sampled to give each one the opportunity of being selected to participate in the study. Systematic sampling also ensured no biases in selection of the participants. In this study every 16th married man was recruited. This was obtained by dividing the total population of married men (6,526) by the sample (396). All the 396 men who were approached to participate agreed to be interviewed. Some men deferred the interview to a later time in the day since they were 26 engaged with other duties, in those cases, the data collector would go back at a given time.

Data Collection

Data was collected by means of a questionnaire. The data collectors did face to face interview with the participants and information was filled on the questionnaire. Permission was also sought from the district commissioner (DC) and the district health officer (DHO). A week prior to data collection, the researcher sought permission of entry into the community through the village head, thereafter a notification was sent to the communities through Health Surveillance Assistant (HSAs) notifying them of the upcoming study in their area. Interviews were done in the participant’s homes on one to one. Home interviews ensured a more natural bounded setting and context that promoted openness. The interview took about 20 to 30 minutes.

Ethical Consideration

Approval was sought from the College of Medicine Research and Ethics Committee (COMREC). Further approval was sought from the District Commissioner for Phalombe district including concerned village heads. As this is a social research, ethical considerations are paramount so that the right things are done in the acceptable manner and at the right time. Any lapse would be harmful to the participants. Ethical issues boarders on informed consent, voluntary participation, privacy and confidentiality and protection from harm. To ensure protection of human rights, participation in the study was on voluntary basis. Informed consent was sought from all the study participants, every participant was informed that they have a right to refuse, to participate or withdrawal during interview and they will not be penalized in whatever way. All those who consented, signed the informed consent form. Furthermore, the A total of 396 married men from six villages in the catchment area of Phalombe Health Center were recruited in the study. The participants were randomly selected in the six villages and interviews took place in their homes. The following were the socio demographic data that was collected from the participants. Age, religion, education level and occupation. Table 1 summarizes the socio demographic data.

researcher ensured that unique codes were used for identification rather than names. The information obtained will only be used for the intended purpose. Completed data collection tools were kept in a lockable safe, all electronic information was kept in a computer with a password. Only the researcher and the statistician will have access to the data for purposes of the study alone. After the study has been accepted and published, all the completed questionnaires will be destroyed.

Socio Demographic Characteristics of the Participants

Source of Information

Those who had ever heard of cervical cancer were 87.9% (n=348). Various sources were mentioned as the source of information on cervical cancer and screening as illustrated by figure

Knowledge on Causes

The study found that 84.1% (n=333) did not know what causes cervical cancer, 13.1% (n=52) mentioned STIs whilst1.8% (n=7) mentioned too much sex, 0.8 % (n=3) said germs and 0.3% (n=1) of the participants mentioned Human Papilloma Virus (HPV) as the cause of cervical cancer. There was a statistical association between knowledge of cervical cancer cause and level of education (χ2=86.498, d.f. = 12, p = 0.001).

Signs/Symptoms of Cervical Cancer

Regarding signs and symptoms, 88.9% (n=352) mentioned that they did not know the signs or symptoms of cervical cancer. 3.3% (n=13) of the participants mentioned vaginal bleeding as a sign or symptom of cervical cancer and another 3 % (n=12) mentioned foul smelling vaginal discharge. The remaining mentioned others.

Knowledge on Cervical Cancer Risk Factors

Participants were also asked on their knowledge on risk factors. Figure 4.2 illustrates the findings. Majority of the participants 75.5% had no knowledge on risk factors, 20.5% had some knowledge and only 4 % were knowledgeable. The study found no association between knowledge of risk factors for cervical cancer and age (χ2 =2.871, d.f. = 4, p = 0.580) or level of education (χ2 =4.286a, d.f. = 6, p = 0.638).

Knowledge on Prevention

Overall, 2.5% of the participants were knowledgeable, 21.2% had some knowledge on prevention whilst 76.3% had no knowledge. The study found that there was no statistical association between knowledge of cervical cancer prevention and age and (χ2 =4.963, d.f. = 4, p = 0.291).

Knowledge on Treatment

Findings showed that only 4.2% were knowledgeable on how cervical cancer can be treated, 68.2% had some knowledge and 27.6% of them had no knowledge. The study found no statistical association between knowledge of treatment and age (χ2 = 7.631, d.f. = 4, p = 0.106).

Knowledge on Screening Eligibility

Overall scores, 93.1% (n=369) had some knowledge, 6.3% (n=25) had no knowledge and 0.5% (n=2) were knowledgeable. The study found statistical association between knowledge on eligibility and level of education (χ2 =26.275, d.f. = 6, p = 0.001). Furthermore the study found no statistical association between knowledge on eligibility and age (χ2 =4.194, d.f. = 4, p = 0.380)

Participation in Cervical Cancer and Screening

Almost all the participants 99% (n=392) said that they would encourage their spouses to be screened for cervical cancer for various reasons. Getting screened for prevention purposes was said by 81.1% (n=321), 8.3% (n=33) mentioned the disease is fatal, 0.6 % (n=2) indicated that as spouses they will also be affected whereas 10% opted for other reasons.

Decision Making

The participants were asked how they would react if their spouse was diagnosed with cervical cancer. The following were the responses, 67.9% (n=269) said they would be sad, 30.6 % (n=121) indicated that they would assist the spouse to seek medical care whilst1.5% (n=6) said they would divorce the spouse. Regarding how men should be involved in cervical cancer screening, 21.7% (n=86) of the participants said there is need for men to be circumcised, 38.6% (n=153) mentioned that men should escort their wives to the health facility, 29.5% (n=117) opted to encourage their spouses with just words whilst 10.2% (n=40) of the participants said they did not know what they can do to be involved. Almost three quarters‟ of the participants mentioned that as husbands, they were responsible for decision making when it comes to cervical cancer screening.

Factors that Affect Cervical Cancer Screening

The study also examined if gender of screening personnel has an impact on utilization of screening services. Majority of the respondents 74% said anyone, male or female can do the screening as long as they are trained to do so, about 20 % said female providers were best suited to do the screening.

Knowledge about Cervical Cancer and Screening

Majority of the participants have ever heard of cervical cancer as a disease that affect women but not in full details. It might be possible that those who had mentioned health workers as their source of information might have acquired the information at VMMC as 97.7% had gone through the procedure. Everyone who goes through this process is counseled on the benefits of the procedure including prevention of cervical cancer. VMMC program offers a window of opportunity to reach out to men with reproductive health information including cervical cancer. However, it seems the information given during VMMC concerning cervical cancer is inadequate because the benefits of circumcision are just outlined during the counseling session prior to the actual procedure. There is need for more information on the benefits, especially on prevention of cervical cancer considering that there is a clear relationship between VMMC, HIV and cervical cancer. VMMC offers a 60% risk reduction in acquisition of HIV and at the same time prevents spread of HPV [10]. It is necessary for VMMC program to comprehensively target prevention of cervical cancer, because evidence from a case control study that examined the relationship between hormonal contraceptives and invasive cervical cancer in South Africa shows that women living with HIV are almost five times more likely to be infected with HPV than HIV negative women, and are likely to develop persistent infection with multiple HPV types [11]. Just a few of the participants‟ spouses have been screened for cervical cancer in this study. These results are similar with several studies that have found low utilization of cervical cancer screening services in Africa [12, 13, 14]. In rural, Zimbabwe Mupepi and colleagues [11] found that only 9 % of the study participants had been screened for cervical cancer. Equally in a cross section study that was conducted in Burkina Faso among women aged between 20 – 50 years of age, only 11.07% of the women had ever been screened for cervical cancer [14]. A study by Hami and friends [12] on intentions to use cervical cancer screening services among women aged 42 and older in Malawi reported that only 24.7% of the study participants had ever been screened for cervical cancer. Underutilization of cervical cancer screening services may be one of the contributing factors of late cervical cancer diagnosis and treatment and might consequently increase morbidity and mortality due to cervical cancer.

Sources of Information

Radio was the most common source of information on cervical cancer and screening followed by health workers. This finding is consistent with a study that was conducted by Nyirenda and colleagues [14] on public engagement in Malawi through a health-talk radio programme which found that men’s participation from the rural area was greater than that of women. This might be attributed to the fact that many people in rural areas especially men rely on the radio for information on different development programmes [15]. Furthermore, with shortage of health workers, the health personnel might be too occupied with other tasks and neglect the health talk component 43 when men seek health care services. There is need for health officials to find other avenues that can be used to reach many communities with cervical cancer and screening messages as other sources of information like the print media or internet might not be feasible especially for rural masses, as was the case for this study. This finding is different from findings of other studies that involved women as their study participants. Women in these studies ranked health workers as the main source of information [3, 16, 17]. The difference in these results might be due to the fact that women tend to visit health facilities more often than men for various reasons as narrated by Bocanegra [7, 18]. It might be during antenatal period, postnatal checks ups, family planning services, under five clinics as well as general outpatient services. Therefore health workers would really come first in terms of source of information in this case whilst in Rosser‟s study, 72.2% of the men who were participants were HIV positive, and their chances of being in contact with health workers were more when accessing ART services. In addition considering the strong relationship that exists between cervical cancer and HIV, the health worker might have mentioned about cervical cancer to majority of them.

Knowledge on Cervical Cancer Cause

Participants in the study did not know that cervical cancer is caused by Human Papilloma virus which is sexually transmitted. This might be due to lack of awareness of the disease in the general population as well as illiteracy level as 66.1% of the 44 participants had either not attended school or dropped out in primary school. As much as majority of the participants have ever attended school, many of them dropped out as such their level of knowledge was minimal. HPV being sexually transmitted is a cause for concern because if married men are engaged in extramarital affairs, spreading of the virus would be rampant and this might increase the risk of HPV

infection to their spouse and then consequently cervical cancer. In polygamous families, as the number of wives increases the risk of HPV infection also increases as explained by Anorlu [2]. Therefore it is important for men to know that as they are being involved in sexual relations with more than one woman, the risk of HPV transmission in their spouses‟ increases. Similar results on low level of knowledge on the cervical cancer cause have also been reported by several studies [18, 19, 20, 16] also found that only 20 % of the study participants knew HPV as a cause of cervical cancer. This is unlike a Ugandan study where some participants believed that too much sex would cause injury to the cervix which might later develop into cervical cancer [20].

Knowledge on Signs and Symptoms

More than three quarters of the participants said they had no knowledge on the signs and symptoms of cervical cancer. These findings show that majority of the married men do not know the signs and symptoms of cervical cancer. This might have an implication on health seeking behavior of the couple. This finding is contrary to what Mwaka, et al. [18] found in Uganda where majority of the participants were able to mention lower abdominal pain, bleeding in between menses, post coital bleeding, post- menopausal bleeding and offensive vaginal discharge as signs and symptoms for cervical cancer. Therefore if men are not knowledgeable of the signs and symptoms, they would delay in assisting their spouses in seeking medical care which might worsen the severity of cervical cancer. However, the level of knowledge on signs and symptoms was dependent on the level of education of the individual. Participants who had gone beyond primary school level were more knowledgeable compared to their counterparts with primary school education and below. This implies that high illiteracy level can impact positively on knowledge about cervical cancer as supported by Aswathy [21, 16] who both observed that men who had education beyond secondary school were more knowledgeable whilst those who had gone up to primary or less had the least knowledge scores.

Knowledge on risk factors

Knowledge scores on risk factors were very low among participants. Having knowledge about risk factors for any condition at least promotes good health seeking behavior or implementation of preventive measures although others have argued that having knowledge does not translate to action [22]. These results are similar with findings from a Ghanaian study that looked at knowledge and beliefs about cervical cancer screening among men in an urban community. Majority of the participants (80%) had either a junior high or high school education, regardless of this only one participant was aware of the risk factors [20]. Similarly, the current study found that education level of the participants was not related to their knowledge on risk factors. In Uganda [18] found that majority of participants could identify multiple sexual partners, cigarette smoking and multiparity as risk factors but this knowledge was not dependent on the socio demographic data of the participants.

Knowledge on prevention

More than half of the participants in the study did not know how cervical cancer is prevented. This low knowledge on prevention has a negative implication on access to cervical cancer screening by women. This is so because if the men do not know how to prevent it, then they would not be in a position to engage themselves in preventive measures that would protect their spouse. Neither would they share correct preventive information with their spouses, friends or families that could positively contribute to the reduction in incidence of cervical cancer. The Ministry of Health launched an HPV vaccination campaign for young girls in Rumphi district, and Zomba city which was a success as a pilot phase [23]. There are plans to scale up to the remaining Districts. This component of prevention is not known to men hence the need for health officials to keep the men informed so that they can consent for their children to have access to the vaccine as well as understand who will really benefit from the vaccine. The ICPD advocates for male involvement so that men should have an insight in reproductive health issues that affect them, their spouses as well as children [24]. Such involvement would enable men acquire knowledge on various issues including cervical cancer and consequently they would be more active in implementing preventive activities including encouraging their spouses to undergo cervical cancer screening. In Malawi, routine health checkups and other screening interventions are underutilized. Majority tend to seek health care when they have a problem. Munthali AC [25], suggests that effective prevention of cervical cancer largely depends on the screening coverage which is not consistent with these findings. Therefore as much as the Malawi government has included cancer in its essential health package, the prevention aspect needs to be expounded. Information on preventive measures need to trickle down to the most remote areas where there are many at risk groups of women. Furthermore, there is need to strengthen the system by ensuring availability of treatment options to maintain positive health seeking behaviors.

However the participant’s level of knowledge on preventive measures and treatment was not related to their age. This result is consistent with Mwaka [18] findings in Uganda where participants’ knowledge was not related to their age. Therefore, information on cervical cancer prevention needs to spread across the communities regardless of the socio demographic data like age.

Knowledge on Treatment

The public health sector offers free services for all in Malawi. As a result, majority of the people report to these facilities most of the times when faced with health problems trusting that the health personnel have solutions for their problem [26]. Findings of the study revealed that most of the participants mentioned that they would be treated at a heath facility with either surgery or drugs. This implies that most of the people trust the health system to cure them of their ailments. Despite that majority of the participants being unknowledgeable about the disease, they had a belief that the health sector has treatment for cervical cancer. These findings are consistent with other findings from Mwaka [18] where participants said cervical cancer can be treated if diagnosed early [26] also found that participants believed that the medical personnel will treat them in case they are found with cervical cancer. These findings depict that health care in Malawi is more focused on the curative aspect than preventive 48 just as in many developing countries [25].

Knowledge on Eligibility

Most of the participants had some knowledge on who is eligible for cervical cancer screening. It is assumed that if men know who is eligible for screening, they would easily influence their spouses to be screened for cervical cancer and in the long run reduce the incidence of cervical cancer [27] but the findings in the study shows that less than 29.8% of the participants‟ spouses had ever been screened for cervical cancer. This finding implies that even though men have the knowledge on who is eligible for screening, they are not putting it to practice as not less than 90% of the participants had some knowledge [28] also found that although participants were aware of screening services, a few had put that to practice. Fewer women have access to screening services making the spouses knowledge irrelevant. The study found that those who had attained education beyond primary education were more knowledgeable on who were eligible for cervical screening [18] also found that people with higher education level are more knowledgeable on cervical cancer. However age was found not to be related to knowledge on eligibility. Overall knowledge about cervical cancer and screening among married men is very low. These results are consistent with the research findings with the finding in other African countries [29, 20, 30] where only few men were knowledgeable about cervical cancer. Although several studies have recommended the involvement of men in reproductive health issues, it seems the messages are not getting across to them as evidenced by the results in this study. Majority of men still have little or no knowledge regarding cervical cancer. This might be attributed to the fact that culturally in Africa, issues to do with reproductive health like child bearing and family planning are regarded as feminine [31, 32]. Similarly because cervical cancer is a problem for women, men may feel less obliged to take responsibility in prevention and treatment. Hence they might have little to no information about it since according to the men, it is a women’s issue. However Asuzu and colleagues in Nigeria found that 70% of the study participants had good knowledge in relation to cervical cancer. This might be due to the fact that about 61.1% of the participants were holders of first degrees and beyond. Evidence shows that individuals who are educated are more knowledgeable of various health issues compared to those who are not educated [16, 15].

Participation in Cervical Cancer Screening Services

Often times married men are decision makers at the household level and mostly determine the kind of health care that their wives can access. Munthali, et al. [25] reported that some women after cervical cancer screening refuse treatment to first consult their husbands. More than half of the participants mentioned that men as heads of families are responsible for making the decisions at home and this includes deciding whether the spouse should access cervical cancer screening. However, almost all the participants said they would encourage their spouses to be screened for cervical cancer for various reasons. Majority of men felt they have an obligation in cervical cancer prevention because they are equally affected sexually, as husbands. This realization offers a turn from the traditional ways of thinking that reproductive health services are mainly for women. Furthermore it opens up an opportunity to reach out to the men and involve them fully in reproductive health issues including cervical cancer. Current evidence shows that men’s support is the center point in increasing coverage to cervical cancer screening and treatment for women [33, 34, 35, 36, 37, 6] and lack of it is a barrier to screening opportunity [38, 27]. Therefore this information should inform policy makers to reach more men with cervical cancer awareness messages as many are willing to let their spouses get screened.

Factors that Affect Screening

Gender of the screening personnel has also been highlighted as a factor that affects uptake of screening services by women [35, 39, 20]. The study found that majority of the participants 73.5% said anyone who is qualified to do the screening regardless of gender can do it. The participants further said that male health workers in this era assist women during delivery and accordingly, it makes no difference to have males providing the cervical cancer screening services. The men’s unbiased attitude towards the gender of the screening personnel provides another window of opportunity that can positively affect scaling up of cervical cancer screening services. This implies that both male and female health workers can be utilized to reach more women with screening services in this area with very minimal resistance to gender preference. However some studies have reported that a female provider is preferred to a male provider due to embarrassment suffered considering that screening is done on a preventive basis [35, 39, 20] Some men mentioned that they should be taught what to look for during cervical cancer screening other than having another male provider visualizing their spouses‟ private parts [20, 25] also found that male health workers negatively affect screening practices. Some of the participants in that study were from Mangochi district which is largely inhabited by Muslims. Evidence shows that Muslims have a strong belief that their wives nakedness is strictly to be seen by their husbands as such a male provider would not be ideal to perform cervical cancer screening [40, 41, 42].