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Table of Contents
ORIGINAL ARTICLE
Year : 2019  |  Volume : 6  |  Issue : 1  |  Page : 7-17

Perceived benefits and barriers toward cervical cancer screening among women ≥15 years in Arsi Zone, Southeastern Ethiopia: Application of the health belief model in a community-based cross-sectional study


1 Asella Zonal Health Office, Department of Non-Communicable Disease and Ethiopia Field Epidemiology Training Program (EFETP), Finfinnee, Ethiopia
2 School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia

Date of Submission17-May-2018
Date of Decision10-Oct-2018
Date of Acceptance16-Oct-2018
Date of Web Publication1-Mar-2019

Correspondence Address:
Dr. Gemechu Chemeda Feyisa
Asella Zonal Health Office, Department of Non-Communicable Disease and Ethiopia Field Epidemiology Training Program (EFETP), Finfinnee
Ethiopia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCRP.JCRP_1_18

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  Abstract 


Introduction: The rate of cancer mortality is18.4/100,000 in Ethiopia, and cancer of the cervix is the second-most common cancer, with an incidence of 16.4/100,000. Cancer of the cervix is easily prevented through vaccinations against human papilloma virus, regular screening, and treatment. Assessing the perception of women with regard to the benefits and barriers of cervical cancer screening among women is important to decrease the barriers and increase the screening rate for early detection. The aim of this study was to describe women's perceived benefits and barriers to cervical cancer screening and their associated factors in Arsi zone, Southeastern Ethiopia. Materials and Methods: This community-based cross-sectional study design was conducted in Arsi zone, Southeastern Ethiopia among 906 women aged >15 years using a multi-stage sampling technique. After data had been coded and entered into Epi info, it was exported into SPSS for analysis. A binary logistic regression model was used to determine associations between sociodemographic characteristics and reproductive variables on the knowledge of cervical cancer and perception of screening at a value of P < 0.05. Results: Most of the participants had higher perceptions of the benefits and barriers to screening (567 [62.6%] and 487 [53.8%], respectively). The women who would like to undergo cervical cancer screening in the future when the service was available were 2.6 times more likely to believe in the benefits of undergoing screening than those who did not wish to undergo screening (adjusted odds ratio [AOR] = 2.3, 95% confidence interval [CI]: [1.2–4.6]). Women living in rural areas were four times more likely to perceive the benefits of cervical cancer screening than those living in semi-urban areas (AOR = 3.9, 95% CI: [1.9–7.7]). Women who started sexual intercourse at age <16 years were two times more likely to perceive barriers to cervical cancer screening than those who started sexual intercourse at age >16 years (AOR = 2.2, 95% CI: [1.5–3.3]). Moreover, the women who had >3 children were 1.5 times more likely to perceive barriers to cervical cancer screening than those who had <3 children (AOR = 1.5, 95% CI: [1.1–2.0]). Conclusion and Recommendation: There were high perceived benefits and barriers to screening in the community. We recommend decreasing the perceived barriers toward screening through education intervention and expanding screening services, as this can increase the uptake of screening in the community.

Keywords: Cervical cancer, health belief model, perceived barrier, perceived benefits, screening


How to cite this article:
Feyisa GC, Temesgen H. Perceived benefits and barriers toward cervical cancer screening among women ≥15 years in Arsi Zone, Southeastern Ethiopia: Application of the health belief model in a community-based cross-sectional study. J Cancer Res Pract 2019;6:7-17

How to cite this URL:
Feyisa GC, Temesgen H. Perceived benefits and barriers toward cervical cancer screening among women ≥15 years in Arsi Zone, Southeastern Ethiopia: Application of the health belief model in a community-based cross-sectional study. J Cancer Res Pract [serial online] 2019 [cited 2019 Jul 22];6:7-17. Available from: http://www.ejcrp.org/text.asp?2019/6/1/7/253243




  Introduction Top


Cancer is a disease in which cells of the body grow abnormally. Cervical cancer is one of the easiest gynecological cancers to prevent through vaccinations against human papilloma virus (HPV), regular screening, treatment, and follow-up.[1]

Cervical cancer is caused by external factors such as persistent infection with certain types of HPV, commonly types 16 and 18, which cause 75% of all causes cervical cancer worldwide, having sex an early age, multiple sexual partner, smoking, diet low in fruit and vegetables, prolonged use of oral contraceptive pills (OCPs), having sexually-transmitted infection (STIs), and multiparity. Internal factors such as inherited genetic mutations suppressed immune condition, and hormones are also risk factors for cervical cancer. These factors may act alone or together to cause cervical cancer.[2],[3]

Globally, more than 266,000 women die annually due to cervical cancer, and it is one of the leading causes of deaths in East Africa and Asian countries.[4] Cervical cancer can be prevented through universal access to prevention and control programs, such as vaccination against HPV and the early detection and treatment of populations at risk. The natural history of cervical cancer is a slow progression in healthy individuals, from the pre-cancerous to invasive stage. It can take from 10 to 20 years from the pre-cancerous stage to cancer stage, which provides many opportunities for interventions such as screening, detection and treatment before the progression to cancer by identifying and preventing factors hindering cervical cancer screening.[5]

The highest incidence rates of cervical cancer and associated mortality affecting women have been reported in Sub Saharan Africa (SSA). This may be due to the absence of screening programs for early detection of precancerous lesions or due to barriers in the perception of women with regard to health-seeking behavior within the countries of Sub Sahara Africa including Ethiopia.[6]

Ethiopia is the 33rd African country with regard to the age-standardized incidence of cervical cancer and 27th with regard to cancer mortality, accounting for 18.4/100,000 population.[7] There are 29.4 million women aged >15 years at risk of cervical cancer, with 7095 of cervical cancer new cases and 4732 deaths annually in Ethiopia. Cervical cancer is the second-most common cancer in Ethiopia, with an incidence of 16.4/100,000.[4]

Cervical cancer is often at an advanced stage by the time the woman seek screening services. This late diagnosis may be due to different perceptions of the women about the disease or absence of services, or the women may not know the risk factors and whether or not they are exposed to the disease.[8] These problems were not well addressed in a previous study in Arsi zone, and thus, the aim of this study was to address these issues.

The health belief model

The Health Belief Model (HBM) is one of the theories of health behavior developed in the 1950s to explain why few people were participating in screening programs to prevent and detect diseases. It proposes that a person's health-related behavior depends on the person's perceptions of the severity of the potential illness, their susceptibility to that illness, benefits of taking preventive action, and barriers to taking action. The HBM is a simultaneous process used to encourage healthy behavior among individuals who put themselves at risk of developing cervical cancer.[9] A person must evaluate their perceptions of susceptibility and the severity of developing cervical cancer. Then, it is necessary to feel threatened by these perceptions. Environmental and sociodemographic factors can also contribute as well as cues to action such as mass media, health professionals, neighbors, friends, and relatives. Finally, the benefits of change must be weighed against the barriers to change behavior to determine that taking action (screening) will be worthwhile.[10]

The HBM postulates that an individual's likelihood of engaging in a health-related behavior is determined by his or her perception of six variables: perceived susceptibility (perceived risk of contracting the health condition of concern), perceived severity (perception of the consequence of contracting the health condition of concern), perceived benefit (perception of the good things that could happen from undertaking specific behaviors), perceived barrier (perception of the difficulties and cost of performing the behavior), cue to action (exposure to factors that prompt action), and self-efficacy (confidence in one's ability to perform the new health behavior).[11] Using this model, we aimed to assess women's perceived benefits and perceived barriers to seeking cervical cancer screening and their associated factors among women in Arsi zone, Southeastern Ethiopia.


  Materials and Methods Top


Study setting and period

This study was carried out in Arsi zone, Oromia Regional State of Ethiopia. Arsi zone is in the southeastern part of the country, and it is one of the 21 zones and 6 special zones found in the Oromia Regional State. According to the 2017 Zonal Health Department (ZHD) report, the zone has 25 districts, 498 rural, and 58 urban kebeles. The area of the zone is 21,120.28 km2 with 42% highland, 28% temperate zone, and 30% lowland. Six hospitals, 102 health centers (HCs), 496 health posts (HPs), 7 government clinics and 2 nongovernment HCs, 256 clinics, and 96 rural drug vendors providing health services for the population. The potential health coverage in the zone in terms of HCs is 85%, and 88% in terms of HPs. The capital town of the zone is Asella, which is 175 km from Finfinnee, the capital city of both the regional state of Oromia and Ethiopia. Arsi zone is bordered to the south by Bale zone, to the southwest by West Arsi zone, to the northwest by East Shewa, to the north by Afar Regional State, and to the east by West Hararghe zone. This study was conducted in four districts (Hetosa, Limmu-Bilbilo, Digalu-Tijjo and Robe Dida'a districts) and 20 selected kebeles in the zone. Only one referral hospital, Asella Referral Hospital, provides cervical cancer screening services, which were initiated in 2010.

According to the 200, population census conducted by the CSA of Ethiopia the projected population of the zone in 2017 was 3,459,322, including 1,728,600 males and 1730 females. About 832,000 of the females were >15 years age. The numbers of urban and rural residents were 493,376 and 2,965,947, respectively.[12] The study period was from February 15 to March 30, 2017.

Study design and population

We performed this community-based cross-sectional study in Arsi zone of southeastern Oromia to assess the knowledge, perceived benefits and barriers toward cervical cancer screening and their associated factors. The study population included women residing in Arsi zone during the study period, all of whom were aged >15 years and residing in the selected districts in the zone. The women aged >15 years in the community at the time of data collection and who agreed to volunteer to participate in the study were included. Women who were critically ill and those with psychiatric problems were not interviewed.

Sample size determination and sampling technique

The base-line of the sample size required for this study was determined by using the formula of single population proportion (n):



n = Sample size required

Zα/2= Confidence interval at 95% (standard value of 1.96)

d = Precision (margin of error) at 5% (standard value of 0.05)

P = Estimated knowledge of cervical cancer (31%) taken from a study in Gonder town of Northwest Ethiopia.[13]



= 329

The most commonly used design effect can range from 1.5 to 3 in a cluster and multi-stage methodology. By considering the design effect of 2.5 in this study: n × D = 329 × 2.5 = 822.5 ≈ 823

The sample size was further increased by 10% due to nonresponse rate or record error.

The final sample size was thus n+ (10% × n) = 823 + (823 × 10%) ≈ 906.

Distribution of participants per four districts and sampling technique

In this study, we included four districts. Therefore, the number of participants was proportionally distributed into the four districts to increase the representativeness of the sample and to reduce sampling bias.

A multi-stage sampling technique was used to select the participants. Accordingly, four districts among 25 districts in Arsi zone were selected using simple random sampling (SRS) technique as primary sampling units. Among the selected districts, five kebeles from each district were selected again using the SRS method as the secondary sampling unit among more than 20 kebeles in each selected district. In each selected kebele, one development army (DA) was selected. In each selected DA, 2–3 development teams (DTs) were selected using the SRS technique. Each DT had a list of households. The first household was selected by lottery method. To obtain the interval (sampling fraction), the number of households in each team was divided by the required sample for that specific team. After completing the selection process women aged >15 years were interviewed from house-to-house according to systematic random sampling by the interviewers using a structured questionnaire until the required sample was obtained. We interviewed around 191–253 women from each district, proportionally allocated sample size for each selected district, kebele and DT with a total of 906 participants in this study.

Study variables

Dependent variables – perceived benefits and perceived barriers).

Independent variables – Sociodemographic variables (educational status, age, place of residence, religion, ethnicity, occupational status, and marital status), behavioral risk factors for cervical cancer (parity, ever exposure to STIs, ever having smoked, ever having used OCPs, early sexual debut, having many sexual partners, age at first pregnancy, a history of abortion, and having partners with many sexual partners previously), and other variables including: monthly income, ever having heard of cervical cancer, ever having heard of screening, and preference of screening.

Data collection

In this study, data were collected using an interview-based structured questionnaire. The instrument was designed based on the study objectives and by reviewing different previous studies with modifications.[14],[15],[16] A data collector was assigned from the Health Extension Workers. After the random selection of five kebeles from each district, the interviewer interviewed eligible participants using the questionnaire moving from house-to-house according to systematic random sampling. The instrument was pre-tested on 5% of the sample size among 45 women in nearby kebeles not included in the actual sample. The clarity of the questions, validity, and logical consistency of the questionnaire was modified accordingly. The instrument was translated into the local language (Afan Oromo) to make the interview clear for the participants, and back to English during data analysis.

Operational definitions and measurements

Likert scale – This is a measurement approach to assess perception responses toward cervical cancer and its screening. A 5-item Likert scale was used (strongly disagree, disagree, undecided, agree, and strongly agree).

Perception – The way in which cervical cancer and screening regarded, understood, or interpreted by the women, and the way the women thought about or understood people with cervical cancer, and screening.

Perceived benefits – View/perception of the benefits of undergoing cervical cancer screening, the results, and positive health outcomes.

Perceived barrier – Perception toward obstacles for undergoing cervical cancer screening.

Perception measurement – The perception, perceived benefits of and perceived barriers to cervical cancer screening were measured based on the 5-point Likert scale. There were four Likert-type items with a maximum score of 4 × 5 = 20 for perceived benefits, and seven Likert-type items with a maximum score of 7 × 5 = 35 for perceived barriers.

High perceived benefits – Women whose score was >17 (85%)/above the mean score on assessment scales of perceived benefits otherwise lower perceived benefits.

High perceived barrier – Women whose score was >24 (69%)/above the mean score on assessment scales of perceived barrier, otherwise low perceived barriers.

Screening – A procedure used to identify cervical cancer lesions among asymptomatic individuals.

DA – Consisting of 12–15 DTs.

DT – Consisting of 20–30 households.

Data processing and analysis procedures

In this study, to assess the perceived benefits and barriers to cervical cancer screening, a scale from 1 to 5 was used, ranging from strongly disagree to strongly agree. To prevent data entry errors, we used manual checks during data collection, including completeness, handwriting eligibility, range and consistency checking, and data analysis screening for outliers during data entry. All of the data were backed-up during data processing.

After data entry into Epi info, it was exported into SPSS version 20 (IBM Corp., Armonk, NY, USA) for further analysis. For descriptive statistics of Likert-type items, frequencies were used. For Likert scale, mean and standard deviation (SD) were used. Binary logistic regression analysis was used to determine the effect of sociodemographic characteristics on screening, perceived benefits, and perceived barriers to screening. Both crude and adjusted measures of associations were considered for all variables. An odds ratio with 95% confidence interval (CI) was used to identify associations. The significance of the association was considered at a value of P < 0.05. Pearson's Chi-square test was used at the primary stage of variable selection into a binary logistic regression model. All significant variables in the Chi-square test were entered into binary and multivariate logistic regression models with the backward stepwise variable entry method. There were 11 items contained in two dependent variables (perceived benefits-4 items and perceived barrier-7 items). Each item of the HBM construct was scored using a 5-point Likert-type scale as follows: 1-Strongly disagree, 2-Disagree, 3-Undecided, 4-Agree, and 5-Strongly Agree. The total score for perceived benefits ranged from 5 to 20, and that of perceived barriers ranged from 5 to 35 scores.

Data quality assurance

To protect the quality of data, the instrument was developed, pre-tested for simplicity, appropriateness, and consistency. The Cronbach's alpha coefficient was calculated to measure the internal consistency of the Likert-type scales using the SPSS to measure the women's perception. Accordingly, the Cronbach's alpha coefficients were 0.801 and 0.707 for perceived benefits and perceived barriers to cervical cancer screening, respectively. The collected data were immediately checked for completeness at each day of recording by the assigned supervisor. In addition to checking data quality during the data collection process, data completeness was checked at the beginning of data entry and before data analysis. To improve the response rate to sensitive questions, female health extension workers were assigned as data collectors, and supervisors with previous experience of supervision were assigned from each district. One day of training was given for both data collectors and immediate supervisors. To maintain the quality of data, overall supervision was conducted by the principal investigator and the immediate supervisors.

Ethical considerations

This study was carried out after ethical approval was given by the Ethics Committee Review Board in Mekelle University, College of Health Science. Moreover, Oromia Regional Health Bureau, ZHD and District Health Offices for the implementation of the study protocol before the study was carried out. Permission was obtained from each kebele administrator where the study took place. During the data collection process, verbal informed consent was obtained from each participant. The participants aged <18 years were asked directly-if their mother was not available at the time of data collection and after permission or verbal consent had been obtained from their father or elders. The names of the participants were not written on the questionnaire during data collection to maintain anonymity.


  Results Top


Sociodemographic characteristics of the study population

In this study, a total of 906 women with age ranging from 15 to 62 years participated in the study, with a mean age of 31.06 years (SD = +7.71). Around half (49.78%) of the study populations were between the age of 25–34 years [Table 1]. Most of the women who participated in the study were married 764 (84.3%), and 61 (6.7%) were single. Regarding the educational status of the study participants, 345 (38.1%) had primary education (1–8 grades), and 238 (26.3%) could read and write but had no formal education. Four hundred and seventy-six (52.5%) women were Muslim, followed by Orthodox Christianity (41.9%). The most prominent ethnic group was Oromo 804 (88.7%), followed by Amahara 97 (10.7%). Seven hundred and sixty-six (84.5%) women lived in rural areas. Regarding the occupational status of the women, most of them 733 (80.9%) were housewives. The average monthly household income was 1378.05 ET Birr (SD = ±1215.57). In 284 (31.35%) of the women, the household monthly income ranged from 500 to 1000 ET Birr.
Table 1: Sociodemographic characteristics of the women who participated in the study in Arsi zone, southeastern Ethiopia, from February to March, 2017

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Perceived benefits of cervical cancer screening

The participants were asked four Likert-type questions that assessed their perceived benefits of undergoing cervical cancer screening. The median for the Likert-type item stating “undergoing cervical was important for women” was “undecided,” meaning that 10% of the study participants had not yet decided the importance of undergoing cervical cancer screening. However, around 49.3% of the study population agreed that undergoing cervical cancer screening was important for women. [Table 2] presents a careful description of the median, mode and frequency of each Likert-type question. The highest percentage point scale of each item described the mode of the item. The majority of the study participants, 567 (62.6%) had higher perceived benefits of undergoing cervical cancer screening with a total mean score of 3.81 [Table 2].
Table 2: Perceived benefits of cervical cancer screening among women in Arsi zone, southeastern Ethiopia, February-March 2017

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Perceived barriers to cervical cancer screening

There can be many barriers to cervical cancer screening in the community. We selected some of the most common barriers to cervical cancer screening in this study. Overall, 365 (40.3%) of the participants agreed that the lack of availability of services was a barrier for not undergoing cervical cancer screening. In addition, 487 (53.8%) women in this study had higher perceived barriers to cervical cancer screening. Moreover, 548 (60.6%) of the women agreed or strongly agreed that a lack of information on where to get the services was a barrier to cervical cancer screening, and 566 (62.5%) of them agreed or strongly agreed that a lack of availability of services was a barrier to cervical cancer screening. As shown in [Table 3], the total score of the study participants (3.16) was >3, which indicated that the majority of them agreed or strongly agreed with the statements of barriers to screening of cervical cancer [Table 3].
Table 3: Perceived barriers to cervical cancer screening among women in Arsi zone, southeastern Ethiopia, February-March 2017

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Perception of women toward people diagnosed with cervical cancer

We then evaluated the perception of women toward people diagnosed with cervical cancer in the community. Seven Likert point items were used to assess the perception of women with regard to the problem of stigmatizing those with cervical cancer. Most (562 (62%)) of the study participants agreed that they felt compassion and desire to help women with cervical cancer. However, 142 (15.7%) agreed or strongly agreed that even though they felt compassion, they tended to stay away from women with cervical cancer. Among the participants, 90 (9.9%) agree or strongly agree that they could not get cervical cancer. Moreover, 125 (13.8%) agreed or strongly agreed that they feared women with cervical cancer because they thought that women with cervical cancer could transmit the disease to them. Forty-seven (5.2%) of the participants agreed or strongly agreed that they had the perception of rejecting people diagnosed with cervical cancer. The majority of the study population, (606 [66.9%]) had lower perceived barriers to people with cervical cancer, with a total mean score of 2.57 [Table 4].
Table 4: Perception of women toward people with cervical cancer in Arsi zone, southeastern Ethiopia, February-March 2017

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Description of perceived benefits and barriers with screening status of women

In this study, we found that the majority of those who had been screened had higher perceived benefits of cervical cancer screening. The majority of not those who had never been screened had higher perceived barriers toward screening for cervical cancer [Table 5].
Table 5: Description of perception with screening status of women in Arsi zone, southeastern Ethiopia, February-March 2017

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Assessment of reproductive health history and the occurrence of risk factors (exposure status) among women toward cervical cancer

In this study, we concentrated on behavioral risk factors, whether the women were exposed to these factors, and whether these factors were associated with knowledge and perception of cervical cancer and screening. With regards to these behavioral risk factors, we asked the participants, whether they had been exposed to STI, history of cigarette smoking, prolonged use of contraceptive pills, age at first sexual debut, number of children (parity), history of multiple sexual partners, and history of abortion.

Among the study participants (n = 906), only 23 (2.5%) had been exposed to STI/HPV. Regarding history of smoking, only 30 (3.3%) of the women had a history of cigarette smoking. These cigarettes were not commercially prepared but, rather culturally home-prepared forms of cigarettes, and it was practiced among the old age (>40 years) groups. Three hundred and four (33.6%) women had ever used OCPs. Among these users of OCPs (n = 304), 277 [91.1%] had used them for <1 year, and the other 8.9% of participants had used them for more than 1 year, (up to 2 years).

Previous studies have suggested that early sexual initiation (debut), in general, age <18 years, is a risk factor for cervical cancer. In this study, the sexual debut of the women ranged from 12 to 29 years. One hundred and seventy-five (20.3%) of the women had a sexual debut at 18 years of age, compared to 193 (22.4%) at <16 years of age and 278 (32.2%) at <17 years of age. Among the participants (n = 906), 44 (4.8%) reported that they had not had sexual intercourse. The age at first pregnancy of the participants ranged from 14 to 31 years. Among those who had been pregnant (n = 831), 140 (16.8%) had their first pregnancy at age <17 years. This study also assessed the sexual history of the women and their partners. Among the participants (n = 906), 38 (4.2%) had >2 partners in their lifetime, and 98 (10.8%) of their male partners had >2 female partners before their marriage took place. Abortion is also another known risk factor for cervical cancer. One hundred and nine (12%) of the study population had a history of at least one miscarriage or abortion.

Factors associated with the perceived benefits of cervical cancer screening

Perceived benefits of screening are one of the constructs of the HBM. A women's perception of the health benefits of cervical cancer screening was assessed during the study as one component of perception measurement. Most, (567 [62.6%]) of the study population had high perceived benefits of cervical cancer screening. Among the many variables analyzed using binary logistic regression, the bivariate analysis indicated that the place of residence, monthly household income >2500 ET Birr and preference for cervical cancer screening were associated with the perceived benefits of cervical cancer screening.

In multivariate analysis, we found that women living in rural areas [adjusted odds ratio [AOR] = 3.9, 95% CI: [2.0–7.7]) and those who preferred to undergo screening in the future when the service was available (AOR = 2.56, 95% CI: [1.2–5.4]) were independently associated with a higher level perceived benefits of cervical cancer screening. The women who preferred to undergo cervical cancer screening in the future when the service was available were 2.6 times more likely to believe in the benefits of undergoing screening than those who did not prefer screening. The women living in rural areas were four times more likely to perceive benefits toward cervical cancer screening than those living in semi-urban areas. [Table 6] presents the bivariate and multivariate logistic regression analyses regarding the perceived benefits of cervical cancer screening.
Table 6: Association among sociodemographic characteristics and perceived benefits of cervical cancer screening among women in Arsi zone, southeastern Ethiopia, February-March 2017

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Factors associated with perceived barriers to cervical cancer screening

As summarized in [Table 7], bivariate analysis showed that the place of residence, parity, early sexual debut, and age at first pregnancy were significantly associated with high a perception of barriers toward cervical cancer screening. However, in multivariate logistic regression analysis, only multi-parity (>3 children) (AOR = 1.5, 95% CI: [1.1–2.0]) and sexual debut ( <16 years) (AOR = 2.2, 95% CI: [1.5–3.3]) were independently associated with barriers to cervical cancer screening. There was no statistically significant relationship between perceived barriers to cervical cancer and other variables. The women who started sexual intercourse at age <16 years were two times more likely to perceive barriers to cervical cancer screening than those with a sexual debut age >16 years. Moreover, the women who had >3 children were 1.5 times more likely to perceive barriers to cervical cancer screening than those who had <3 children.
Table 7: Sociodemographic and reproductive variables associated with perceived barriers to cervical cancer screening among women in Arsi zone, southeastern Ethiopia, February-March 2017

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  Discussion Top


This study assessed the general aspect of women's perception towards the benefits and barriers to undergoing cervical cancer screening among mainly rural communities of Arsi zone in southeastern Ethiopia. The women were asked about their perception toward screening using the HBM constructs [perceived benefits and barriers toward cervical cancer screening]. Perceived benefit and barrier associated factors were also assessed during the study. The prevalence of cervical cancer screening was <1%, which is very low compared to other studies in Ethiopia[13] (14.7%), Uganda-Masaka (7%),[17] Kenya-Kisii town (16.6%),[18],[19] Burkina Faso (11.07%),[20] and Vietnamese Americans (53%).[21] According to the national cancer control of Ethiopia, the target is to achieve 80% cervical cancer screening coverage in the population from 2016 to 2020,[12] which may be a challenge considering a baseline of <1% in this study.

We also found that 87% of the study participants would choose to undergo cervical cancer screening if the service was available or in the future. However, 13% of the study participants did not want to use screening services and did not prefer any health professionals for screening due to fear of the procedure, believing that they were not at risk of developing cervical cancer, embarrassment, and their husband not recommending the service. Despite differences in some variables, this study is mostly consistent with a systematic review on barriers to utilization of cervical cancer screening in Sub-Saharan Africa and Nigeria[22],[23] which indicated that fear of the procedure and negative outcomes, embarrassment,[24] low level of awareness, lack of privacy, lack of husband support, social stigma, accessibility, and cost of services were barriers to screening.[25]

Moreover, we found that the area of residence of the women and their preference to undergo cervical cancer screening were predictors of high perceived benefits of cervical cancer screening. The women living in rural areas were four times more likely to perceive the benefits of screening for cervical cancer than those living in semi-urban areas. This may be because more women in semi-urban areas had a low perception of threats than those in rural areas. On the other hand, the women who wanted to undergo cervical cancer screening in the future were 2.6 times more likely to perceptive the benefits of cervical cancer screening than their counterparts. In addition, multiple sexual partners, ever having smoking, age, being married, and parity were not predictors of cervical cancer screening benefits, which is similar to a study on Botswanan women[16] in which no significant association was found between sociodemographic variables and perceived benefits of cervical cancer screening. However, our findings are not consistent with another study from Ethiopia (Mekelle town)[26] which showed that the aforementioned variables were predictors of the benefits of cervical cancer screening and in Portland (Jamaica).[15] The discrepancy between this finding and our study may be due to differences in the study populations and setting. The current study was mainly focused on rural communities, where-as the study in Mekelle focused on urban communities.

Although many variables were assessed in this study, only parity and sexual debut were independently associated with a higher perceived barrier to cervical cancer screening. This may be due to the women's perception that multiparity and early sexual debut can cause cervical cancer. In another study conducted in Kenya, parity was not associated with being a barrier to cervical cancer screening;[27] however, our findings are consistent with those that ever having used oral contraceptives was not associated with a barrier to cervical cancer screening. In this study, there were no significant associations among the sociodemographic data (including age, education, occupation, and religion) and perceived barriers to cervical cancer screening. This is similar to a study in Malaysian women[28] which suggested that age, employment, and ethnicity were not associated with perceived barriers to cervical cancer screening.

Strengths and limitations

Regarding the strengths of this study, we used a large sample size covering mostly rural residents. Hence, to the best of our knowledge, the representativeness of the study was not compromised. Moreover, the quantitative application of HBM in addressing the women's perception toward screening was another strength of the study. In addition, as part of perception assessment, we described the issue of stigmatizing people with cervical cancer. To the best of our knowledge, no previous studies have addressed this issue. Despite its strengths, this study might have some limitations. There could be social desirability bias due to the nature of self-reports and interviewer-based administered questionnaires, and the women might have preferred to respond positively in a socially acceptable manner, particularly with regards to reproductive history, risk factor assessment and barriers toward people diagnosed with cervical cancer. This may have affected the true prevalence of the risk factors and the underlying reality of perception in the community.


  Conclusion and Recommendation Top


A small proportion of the population did not want to undergo screening due to fear, embarrassment, the perception of not being at risk, and the absence of a recommendation from health professionals. Preferences of screening, place of residence, parity, and age at first pregnancy were independent predictors of perceived benefits and perceived barriers to screening. About half of the study population stated that they had not been screened due to the absence of screening services. Moreover, the majority of the study population had high perceived benefits and perceived barriers toward cervical cancer screening.

Decreasing perceived barriers toward screening should be emphasized through education interventions and expansion of screening services, as this can increase the uptake of screening in the community. We recommend that maternal and child health officers should be stationed at each district, to improve awareness of cervical cancer and the benefits of screening and reduce barriers to screening among women. This study did not address all of the possible barriers to cervical cancer screening or detailed perceptions of the stigmatization of cervical cancer. Therefore, we suggest that further studies should be conducted to provide insight into the other domains of barriers to cervical cancer screening and perceptions of women toward women with cervical cancer. Generally speaking, the findings of this study can be used as a baseline for the development and implementation of health education interventions targeting cervical cancer and screening among rural communities thereby reducing the incidence of cervical cancer in the country.

Acknowledgment

We gratefully acknowledge all of the women who participate in this study for their time and cooperation during the data collection period. Moreover, the authors would like to thank the data collectors, supervisors, and administrators of each public health institution where the study took place for their valuable contribution to the study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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