FACTORS ASSOCIATED WITH CERVICAL CANCER SCREENING. A CASE STUDY OF MUKONO MUNICIPALITY
BY
BYARUHANGA CHRIS
BPS (Mak)
A DISSERTATION SUBMITTED TO THE DIRECTORATE OF RESEARCH AND GRADUATE TRAINING IN PARTIAL FULLFILMENT OF THE REQUIREMENTS FOR THE AWARD OF DEGREE OF MASTER OF SCIENCE IN POPULATION AND REPRODUCTIVE HEALTH OF MAKERERE UNIVERSITY
JANUARY, 2018
i
ii
Dedication This research work is dedicated to my wife, Agatha Byaruhanga, Mr. and Mrs. Kiconco K Patrick, Mr. and Mrs.Bakiga Goddie Willy, my entire family, School of Statistics and Planning, Makerere University, Mukono District Health Officer (DHO), Misinde Cyprian (PhD), Asiimwe JohnBosco (PhD), Dr. Godwin Turyasingura, John Mushomi (PhD), Ven. Can. Enos Kagodo, Ven. Can. George William Kittyo, Rev. Wilson Senkanga, Rev. Daniel Balabyekubo, Rev. Merab and Rt. Rev James William Ssebagala of Mukono Diocese for their physical and spiritual support towards my academics at Makerere University.
May God be gracious to you, make His face shine on you and bless you (Psalms 67:1-2).
iii
Acknowledgement Enormous thanks go to Almighty God and His Son Jesus Christ for good health and wisdom that enabled me to produce this work.
I thank my supervisors Asiimwe JohnBosco (PhD), Dr. Godwin Turyasingura and all my lecturers who were more than generous with their expertise required for proposal development, data collection and writing of this dissertation.
I would like to acknowledge and thank Ass. Prof. Robert Wamala, Misinde Cyprian (PhD)-the head of population studies, School of Statistics and Planning for granting me the approval to conduct this research.
I appreciate Kiconco K. Patrick, Barbra Bakiga, Claire, Kenneth, Graham, Pearl, Alex, Maama Asiimwe, Rt. Rev. James William SSebagala, and Ven. Can. Rev. George W. Kityo, Rev. Wilson Senkanga, Rev. Daniel Balabyekubo, Rev. Merab, and Ven. Enos Kitto Kagodo for their physical, spiritual and emotional support.
I also wish to thank my research assistants; Allan, Douglas, Sam, and Joseph who collected the data for this dissertation, and I wish to acknowledge and thank all the females who participated in this study. Their willingness to respond to the research made the completion of this research an enjoyable experience.
Finally, I extend special thanks to all my student colleagues especially; Richard Imarkit, Stephen Eduru, Evelyn, Diana, William, Jonas, Fred, Peace, Liz, Daisy, Victoria Nabbona, and Amex for their overwhelming assistance and encouragement in the academia.
iv
Table of Content Declaration ...... Error! Bookmark not defined. Approval ...... Error! Bookmark not defined. Dedication ...... iii Acknowledgement ...... iv List of Acronyms ...... vii ABSTRACT ...... viii CHAPTER ONE: INTRODUCTION ...... 1 1.0 Background ...... 1 1.1 Problem statement ...... 2 1.3 Objective of the study ...... 2 1.5 Conceptual frame work ...... 4 1.6 Structure of the dissertation ...... 6 1.7 Scope of the study ...... 6 1.8 Operational Definitions ...... 6 CHAPTER TWO: LITERATURE REVIEW ...... 7 2.0 Overview of cervical cancer screening ...... 7 2.1 The literature related to the study...... 7 CHAPTER THREE: METHODOLOGY ...... 10 3.0 Introduction ...... 10 3.4 Data collection techniques and tools ...... 11 3.5 Data management and analysis ...... 12 3.6 Ethical considerations ...... 13 CHAPTER FOUR: STUDY FINDINGS ...... 14 4.0 Introduction ...... 14 4.1 The narrative form of the univariate analysis results ...... 14 4.2 Socio-economic, demographic factors with HPV screeninguptake ...... 18 4.3 Factors associated with cervical cancer screening uptake ...... 21 4.4 Discussion of findings of study based on predictors in the final model...... 22 CHAPTER FIVE: SUMMARY OF THE FINDINGS, CONCLUSIONS AND RECOMMENDATIONS ...... 27 5.0 Introduction ...... 27 5.1 Summary of the findings ...... 27 5.2 Conclusion ...... 27 5.3 Recommendations ...... 28
v
LIST OF TABLES TABLE 4.1: DESCRIPTIVE ANALYSIS OF SOCIO -ECONOMIC , DEMOGRAPHIC AND OTHER FACTORS ...... 15 TABLE 4.3. A BINARY LOGISTIC REGRESSION (BLRM) TO DETERMINE PREDICATORS ...... 21
LIST OF FIGURES FIGURE 1: CONCEPTUAL FRAME WORK ...... 5 FIGURE 4.1: BAR GRAPH PRESENTING BARRIERS TO ...... 17
LIST OF APPEDICES APPENDIX 1: CERVICAL CANCER SCREENING STUDY HOUSEHOLD TOOL , 2016 ...... 32 APPENDEX 2: DECLARATION OF ORIGINALITY FORM ...... 40 APPENDIX 3: RESEARCHER ’S STATEMENT ...... 41 APPENDIX 4: INTRODUCTION LETTER ...... 42 APPENDEX 5: A MAP OF MUKONO DISTRICT ...... 43
vi
List of Acronyms
ACCP Cervical Cancer Prevention for Africa
ANC Antenatal Care
AORs Adjusted Odds Ratios
ASPIRE Advances in Screening and Prevention in Reproductive Health
BCC Behavioural Change Communication
DHO District Health Office
HIV/AIDS Human Immune Virus/Acquired Immune deficiency syndrome
HPV Human Papilloma Virus
IARC International Agency for Research on Cancer
ICC Cervical Cancer Incidence
ICO Information Centre on HPV
IEC Information Education Communication
KNBS Kenya National Bureau of Statistics
BLRM Binary Logistic Regression Model
MTRH Moi Teaching and Referral Hospital
NCBI National Center for Biotechnology Information
NGOs Non-Governmental Organizations
PNC Post Natal Care
UBOS Uganda Bureau of Statistics
USA United States of America
W.H.O World Health Organization
PAP Papanicolaou test
AFS Age at First Sexual intercourse
AFM Age at First Marriage
vii
ABSTRACT The main objective of the study was to assess the factors associated with knowledge and attitudes towards cervical cancer screening that could influence females to undertake cervical cancer screening.
Cross-sectional descriptive study of 384 women aged 15-49 was done using an interviewer- administered questionnaire. At bivariate level of analysis, chi-square tests were used and logistic regression analysis was performed at multivariable level. The model’s results show that the younger women had less odds of HPV screening uptake (0.623, P=0.002) compared to the older ones while post-secondary educated women had higher odds of HPV screening uptake (OR=1.525, P=0.000) compared to those who had primary education. While as, women in the highest wealth quintile had higher odds of HPV screening uptake (OR=1.363, 0.000) compared to those in lowest wealth quintile, Muslim women had less odds of HPV screening uptake (OR=0.655, 0.001) compared to their counterparts (Christians). In addition, women who had knowledge about HPV and screening had higher odds of HPV screening uptake (OR=33.4, P=0.000) compared to the ones with no knowledge while as women with low attitudes towards HPV screening had less odds of HPV screening uptake (OR=0.014, P=0.00) and the women who reported “ignorance” as the major barrier to cervical cancer screening had less odds of HPV screening uptake (OR=0.711, P=0.001) compared to their counterparts and unmarried women had higher odds of HPV screening uptake (OR=1.610, P=0.003) compared to the married.
Conclusively, the study showed low uptake of HPV screening (38% of 384 women) who undertook screening due to the majority of women who were young, less educated, low income earners and ignorant about cervical cancer and screening.
Therefore, this study recommends the concerned initiatives, the government, private partners to revise and strictly implement HPV preventive policy programs; integrate HPV screening into health programs such as anti- HIV/AIDS/Malaria programs (for example, BCC), and incorporating HPV screening program into the education curriculum of Uganda in order to increase women’s awareness, knowledge, motivation and participation in HPV screening, hence reduce HPV prevalence and mortality rates due HPV in Mukono Municipality and in Uganda as a whole.
viii
CHAPTER ONE: INTRODUCTION
1.0 Background Cervical cancer is the second most common cancer among women Worldwide and is the leading cause of death in developing countries which is largely caused by HPV type 16 and 18, transmitted through unprotected sexual intercourse (Chakravarty, 2014). Uganda’s cervical cancer prevalence is about 34% (Mukama, Ndejjo, Musabyimana, Musoke and Halage, 2017). Cervical cancer screening rate has been low in Africa ( 1%-14% in rural areas, 2%-20% in Urban (Asiimwe, Whalen, Tisch, Tumwesigye and Sethi, 2010) of which East Africa screening rate is almost in the same rage (5%-30%).
Several studies show that Uganda has low cervical cancer screening rates (4.8%-30%), Central Uganda registering 7% HPV screening rate in 2015 (Twinomujuni, Nuwaha, and Babirye, 2015) which has contributed to 20% to 25% of all cancers among women in Sub-Sahara Africa (Abotchie, Shokar, & Nakalevu, 2009) and to a higher cervical cancer incidence in Sub- Saharan countries range from 30 to 40 per 100,000 women (Wabinga, Kahesa, Mwaiselage, Ngoma , Kalyango and Karamagi, 2008).
Screening is a universally accepted early detection strategy; yet, the utilization of cervical cancer screening in many developing countries is still poor. A 2008 review showed that among women in need of cervical cancer screening, an average of 19% in developing countries had been screened of HPV in the last three years compared to 63% in the developed countries (Gakidou, Nordhagen and Obermeyer, 2008)
Low cervical cancer screening rates are not only due to low knowledge and poor attitudes towards cervical cancer screening, but also due to socio-economic, demographic factors and accessibility factors associated with undertaking cervical cancer screening (Bajunirwe and Muzoora, 2005); moreover, there is no current systematic review of what works in developing countries to increase women’s uptake of screening services, or the reasons that discourage or motivate them to do so (Bukirwa, 2015).
1
1.1 Problem statement Cervical cancer screening is one of the effective interventions against cervical cancer in Uganda. This aims at detecting infection with HPV and precancerous cells (Bener, 2001) and a 2008 review showed that among women in need of cervical cancer screening, an average of 19% in developing countries had been screened in the last three years, compared to 63% in developed countries (Gakidou et al., 2008).
There is low screening uptake in Sub-Saharan Africa (about 5-25%), and baseline lifetime screening rate for cervical cancer in Uganda is reported to be between 4.8% and 30% (Campos, 2016). HPV screening in Uganda is erratic, opportunistic, and in some places absent due to socio-economic, demographic and access factors. This translates to staggeringly low screening uptake of 4.8% in rural Uganda (Ndejje et al., 2016).
The resent study done in 2003 showed very low screening rate of 7% in Central Uganda which can suggest Mukono being neighboring Kampala has lower HPV screening rates, thus putting (15-49 years) women at high risk of developing the HPV. It is via regular HPV screening that the abnormal changes in sexually active women are detected and destroyed before the result into outright HPV and death in it’s advanced stage, thus motivating the researcher to carry out the study to inform the concerned initiatives to encourage women’s full participation in HPV screening in order to reduce HPV rate and women mortality.
1.3 Objective of the study This section consists of the main and specific objectives of the study. 1.3.1 Main objectives of the study Assess the factors associated with cervical cancer screening uptake in Mukono Municipality.
1.3.2 Specific objectives 1. Assess the association between demographic factors, and HPV screening uptake. 2. Assess the association between socio-economic factors, and HPV screening uptake 3. Examine the association between enabling factors and HPV screening uptake 4. Examine the relationship between the selected socio-economic, demographic, enabling factors, and regular cervical cancer screening uptake.
2
1.3.3 Hypotheses 1. Younger women are associated with reduced odds of HPV screening uptake. 2. Unmarried women are associated with increased odds of HPV screening uptake. 3. Women with post-secondary education are associated with increased odds of HPV screening uptake. 4. Muslim women are associated with reduced odds of HPV screening uptake. 5. Women in the highest wealth quintile are associated with increased odds of HPV screening uptake. 6. Women who resided 1km or less from the health facility are associated with increased odds of HPV screening uptake. 7. HPV Ignorant women are associated with reduced odds of HPV screening uptake.
1.4 Justification Although regular Pap smear tests (Papanicolaou tests) can screen HPV, access to preventive screenings may be nearly non-existent in resource poor settings in which Mukono-Uganda lie due limited resources to encourage regular screening across the country, lack of basic health education and factors that socio-economic health care needs access and demographic factors (Asiimwe et al., 2016). Mukono district shares most of common characteristics with it’s neighboring district Kampala (central Uganda) in health services delivery and utilization, therefore, Kampala having low cervical cancer screening rates of about 7% posed a great assumption that screening rates in Mukono might be lower, thus necessitated this study.
Based on the 2015-2016 Ministry of Health records, Mukono Health Centre IV showed increasing cases of HPV; 26 women were malignant, HPV and 59% were HPV positive (Mukono District Health report, 2016), this might have contributed to low HPV screening uptake in the district which might have also been influenced by socio-economic, demographic, women’s HPV knowledge, attitudes and access factors, Finally, the gaps in selected authors’ literature called for this study; for example; Asiimwe et al., (2010) left out some important variables associated with HPV screening uptake such as parity, AFM, AFS, household head support and religion, Government policy on HPV, thus justifying the study to give insight to concerned initiatives on approaches that would increase HPV screening rates in Mukono and Uganda.
3
1.5 Conceptual frame work This study adopted (Andersen, 1995)’s Behavioural Model of Health Services (fourth phase). The model is useful in assessing the association of health utilization (like HPV screening upatake). It provides measure of access to medical care (Andersen, (1995). He discribed these three major componets as follows: Predisposing factors which are indivivdual factots such as demographic (age, Age at first Marriage, socio-economic and demoraphic factors), enabling factors, and needs factors.
The respondents’ individual background characteristics could influence enabling factors which can influence women’s perceived health needs and affect their health behavior, hence influencing women to up take cervical cancer screening. Health behaviors also influence enabling factors which in turn effects needs factors, hence influencing women’s decision to up take cervical cancer screening.
Health behaviors also influence enabling factors which would influence the needs factors hence the practice of cervical cancer screening. There is direct interaction between enabling factors and the outcome, between predisposing factors and the outcome variable as viewed in the frame work (Andersen et al., (1995).
4
PREDISPOSING FACTORS
• Age, AFM, AFS OUTCOME (Evaluated • Parity health status) • Marital status • Ever had HPV • Education level screening • Residence • wealth status • knowledge • Religion
HEALTH BEHAVIOUR ENABLING RESOURCE • Personal • Government policy adherence behaviours • • Transport means (distance to Frequency of visits to doctor the H.F) • Visiting Health • Access to Health Facility) Facility • Household head • Waiting time • Health workers’ attitudes • Source of information
NEEDS FACTORS • Perceived need • Fear of having cancer • Screening process • Gender concerns (Respondent preference of health) • Cost of treatment • Fears of Pap smear examination • Attitudes
Figure 1: Conceptual frame work
5
1.6 Structure of the dissertation This dissertation consists of five chapters; chapter one contains background to the study, statement of problem, objectives, hypotheses, justification of the study, scope of the study and conceptual frame work. Chapter two consist of review of literature on cervical cancer screening in association with respondents’ predisposing factors such as socio-economic, demographic, knowledge enabling factors such as health services, financing, transport, household head support, health behaviors and needs factors, attitudes on cancer. Chapter three describes the methodology of the study indicating the source of data, study variables, data analysis, ethical, strength and limitation of the study. Chapter four presents descriptive statistics of these independent variables, cross-tabulation and binary logistic regression model and discussion of results. Chapter five presents the summary of the findings, conclusions and recommendations.
1.7 Scope of the study The study was conducted in Mukono Municipality using a sample of women (15-49 years) selected from households in the selected villages of selected two wards per division. The content scope covered factors such as socio-economic, demographic status of women, accessibility factors, and other factors like knowledge on HPV and attitudes towards cervical cancer screening. The study covered the period of academic year 2015/2016.
1.8 Operational Definitions Cervical cancer: Cervical cancer is the cancer that forms in tissues of the cervix (the organ connecting the uterus and vagina (Murungi, 2014). Screening: Screening refers to the use of simple tests across a healthy population in order to identify individuals who have cervical cancer but do not yet have symptoms (WHO, 2013). Attitude: Women’s perceptions, willingness and feeling towards cervical cancer screening Knowledge: The facts about the cervical cancer risk factors, symptoms, signs, and about regular cervical cancer screening (Murungi et al., 2014). Pap smear test (Papanicolaou test) is a procedure that is used to test HPV in sexually active women.
6
CHAPTER TWO: LITERATURE REVIEW
2.0 Overview of cervical cancer screening Cervical cancer screening is one of the effective interventions against cervical cancer in Uganda. This aims at detecting infection with HPV and precancerous cells (Bener et al., 2001) destroying them before they result into outright cancer. A 2008 review showed that among women in need of cervical cancer screening, an average of 19% in developing countries had been screened in the last three years, compared to 63% in developed countries (Gakidou et al., 2008). Uganda aims at reaching 90% of Ugandans with cervical cancer information, education and communication materials, and increase HPV screening up to above 80% of eligible women aged 25– 49 years (Ndejjo et al., 2017), however, HPV screening rates are still low in Uganda od about 4.5-30% and Central Uganda registering about 7% PHV screening rate in 2015 (Twinomujuni et al., 2015).
2.1 The literature related to the study
A study carried out among Kisumu women at Jaramogi hospital showed that knowledge level on the signs and symptoms of cervical cancer was an important determinant for being screened for cervical cancer (Morema, Atieli, Onyango, Omondi and Ouma, 2014) which was in agreement with Lyimo and Beran, (2012) in their study findings in Moshi, Tanzania. They found out that Women with low knowledge levels on HPV had less odds of screening uptake compared to those who had knowledge of HPV Pap smear test. The findings of Abotchie et el., (2009) revealed that women who had knowledge on HPV risk factors and preventive measures such HPV screening had less odds of cervical cancer uptake compared to those who had knowledge (Peter, and Abotchie et al., 2010). Which was in agreement with Ndejjo et al., (2016)’s study findings that showed that women who knew at least one test for cervical cancer were significantly associated with increased odds of HPV screening uptake undertake similar to Muwasi and Ndikabona, (2017)’s findings in Oyam were in agreement; they reported that women with knowledge on HPV had higher odds of up taking cervical cancer screening compared to those with no knowledge on the disease.
7
A study was conducted in Kuwait with aim of assessing the knowledge on HPV, attitude and practice regarding cervical cancer screening found out that of the 300 married, only 31% of had positive attitudes and about 24% had ever been screened for cervical cancer (Morema, 2014). This was in line with Wong, (2010) who reported that women who had positive attitude towards cervical cancer testing had perceived that they were at risk of getting infected and had to seek screening services while those who did not perceive that they were at risk of developing HPV cancer were negative about cervical cancer screening.
In addition, the study conducted by Ndejjo et al., (2016) showed that women’s positive attitudes (those who were willing to test for HPV at available screening point) were significantly associated with increased odds to uptake cervical cancer screening. Nsubuga, Muwasi and Ndikabona et al., (2017) in Oyam found poor attitudes among women about HPV screening which led to low screening rates of about 2% in Eastern Uganda.
The study findings of Asiimwe et al., (2010) revealed that women of about 45 years were significantly associated with positive attitudes towards HPV prevention by timely cervical cancer screening. In addition, Tusingwire and Nsubuga, (2017) found a significant relationship between older women, and increased knowledge on HPV. As this large cohort of young people enters the childbearing years, their reproductive behavior will determine their future being at high risk of maternal mortality (Asiimwe et al., 2010) , however Birungi et al., (2016) agrees with Asiimwe et al., (2016) by stating that older women were associated with increased cervical cancer screening uptake.
Aruba, (2010) in his study among 384 mothers focused on the association marital status with HPV knowledge and attitudes toward HPV screening but little attention was given to assessing the association of marital status with cervical cancer screening uptake which was done by this study. Similarly, Asiimwe et al., (2010) findings showed the significance that unmarried women had with HPV knowledgeable. Some studies have also found out that single women were more likely than married women to have Pap smear screening (Singh, 1998).
8
Whalen et al., (2010)’s study findings showed that women who lived in urban and in semi- urban areas were not significantly associated with positive attitudes towards cervical cancer screening. Urban and semi-urban women could not go for cervical cancer screening because they claimed that they were too busy to go to the HPV screening Centre. And some reported that they did not know the risk factors of HPV.
The findings of Aruba et al., (2010) among 384 mothers, female guardians of vaccinated girls showed that women’s highest level of education was significantly associated with increased knowledge of risk factors, signs, symptoms and Pap smear test for cervical cancer in agreement with Ngonzi and Ndejjo et al., (2016) who found out that women who had post primary education were not associated with increased odds to undertake cervical cancer screening.
The wealth status of females is one of the major determinants of accessibility to health facility and services, HPV screening in particular. The study conducted among 219 women attending MNCH-FP clinic at the hospital in Kenya, Eldoret at the Moi teaching and referral hospital carried out a descriptive analysis to determine the majority of women who could not afford cervical cancer screening due to limited finances (Belete, 2015).
Ndejjo et al., (2017) found out that long distance to the screening Centre was significantly associated with reduced women’s intention to undertake cervical cancer screening which was in agreement with the findings of (Nastasi, cited in Nakalevu et al., 2009) that revealed that women’s beliefs about cervical cancer screening and attendance are the best predictors of uptake of the service, even when organizational aspects are taken into account.
The study carried out by Jia, (2013) identified the main barriers to participation in cervical cancer screening as “Anxious feeling once the disease was diagnosed”, “No symptoms/discomfort”, “Do not know the benefits of cervical cancer screening”, “Afraid of pain during cervical cancer screening”, “cancer of the cervix is incurable even if screening is effective” and “husband disapproves of cervical cancer screening”.
9
CHAPTER THREE: METHODOLOGY
3.0 Introduction This chapter presents the methodology adopted in guiding the study. It includes details on study design, area, population, data source, study variables, measurements, sampling techniques, analysis strategy and limitations to the study.
The study was conducted among the women in the reproductive age 15-49 years in Mukono Municipality. Mukono Municipality neighbours Kalagito to the North, Kira Town to the West, Lake Victoria to the South, Lugazi to the East. It lies 27 kilometres (17 miles) East of Kampala- Capital City of Uganda. A cross-sectional descriptive study was adopted with an aim of assessing the factors that are associated with cervical cancer screening among these women. 3.1 Sampling Approach The study used clustered, simple random and systematic sampling techniques. Clustered sampling was employed to obtain two wards in the two divisions (Goma and Mukono Central) that are in Mukono Municipality. Wards in each division were listed and two were selected by simple random sampling. In Goma division, Seeta and Nataburirwa wards were selected among Nyenje, Misidye and Bukeerere while Namumira and Ggulu wards were selected among Ntaaho, Ggulu, Nsuube, Mukono town, Nabuti wards in Mukono central division. Villages in each respective ward were listed and two villages were selected by simple random sampling; therefore, Kkolo and Namilyango were randomly selected among Kasokoso, Namilyango, Mawotto, Kiwanga-Lwanda, Degeya, Kkolo, Kitale villages of Nantaburilwa. Similarly, Gwafu and Baggala in Seeta ward were randomly selected among Kirowooza, Seeta LCIII, Gongobe, Ntinda, Njerere, Gulama, Bugoba and Nabuta villages. Hamu-Mukasa and Kitete were randomly selected among Nyandu, Ssaza, Ggulu-A, Agip, Colline, Kirangira of Ggulu ward and Namumira and Ddandira villages were randomly selected among Kitega, Kavule, Kigombya and Anthony Basiima villages of Namumira Ward in Mukono central division. The households were selected in each village by systematic sampling technique where 384 households were selected and visited. All available, legible respondents including female house hold heads with the help from selected households were interviewed.
10
3.2 Sample size Sample size was determined by use of proportions;(Cochran, 1998)’s equation to yield a representative sample for proportions since the study population (females in the reproductive age) proportion was unknown.
Cochran, 1998’s Formula; z 2 pq no = ………………………………………….…….3.2(a) e 2 no= Sample size for an infinite population e= precision of the study ± 0.05 z= standard normal deviate corresponding to 95%, confidence interval =1.96 q= (1-p); p is the proportion of females who had ever screened for HPV. p was unknown so the researcher used 50%. 95.1 2 × 5.0 (1 − 5.0 ) no = = 384 ………………….………………3.2(b) 0.05 × 0.05
3.3 Eligibility criteria All females aged 15-49 years who consented to participate in the study and had resided in the study area for more than 6 months were considered for participation in the study.All females who refused to consent, or they were sick at the time of the study were excluded from participating in the study.
3.4 Data collection techniques and tools The study used Interviewer administered questionnaire in data collection through household visits and interviews. Individual semi-structured interviewing was preferred because of being useful in providing detailed information about females’ knowledge of cervical cancer, attitudes, and their practice to undertake cervical cancer screening in order to explore new issues in detail (Kuper, 2008). Before data collection, the questionnaire was pre-tested in neighboring County-Nakifuma according to the objectives of the study. Four research assistants with a diploma were thoroughly recruited to assist in the data collection based on study objectives and ethical guidelines.
11
The study dependent variable was “cervical cancer screening uptake” while Age of respondents, Age at First Sex, Age at First Marriage, Marital status, Residence women’s knowledge, Religion, Education level, Wealth status and Parity (Number of children per women) were independent variables considered under this study. Other factors; enabling factors and needs factors that could influence cervical cancer screening were included in the analysis. Some of these were; women’s attitudes, frequency of seeing the doctor, and access to the heath facility, the sex of health provider, Government policy, sex of medical worker preferred by respondents and availability of screening services.
3.5 Data management and analysis Descriptive analysis was run using SPSS to get frequencies and percentages. It’s worth stating that wealth index was derived to determinate the wealth status of the respondents as seen below;
Household items that were used to calculate wealth index include; television, radio, car, motorcycle, bicycle, refrigerator, sideboard, motorcycle, phone, sofa seats, dwelling characteristics like building structure; permanent, temporary, semi-permanent or a hat, drinking water source, and the source of lighting.
Information collected on the above was assigned a factor score generated through principle component analysis. The resulting asset scores were standardized in relation to standard normal distribution with a mean of zero and standard deviation of one. Each household was assigned a standardized score for each asset, where the scores differed according to the ownership of an asset. These scores were summed by the researcher and females in the household were ranked depending on the total scores of the households they resided during the study period.
The sample was then divided into population quintile (five groups with the same number of individuals in each) meaning that 20% of the population with the lowest total asset score became women in the lowest wealth quintile, the next 20% of the population in the second quintile, 20% of the population in middle, and so forth. Approximately 20% of population would be in each wealth quintile.
12
“The first and second wealth quintiles”, “the highest and fourth wealth quintiles” were classified in their respective categories as one since they had similar characteristics of the respondents in this study, thus “lowest”,” “highest” and “middle” wealth quintiles were categories created respectively.
At bivariate level of analysis, Chi-Square was adopted to assess the association between independent variables, enabling factors, needs factors, and up taking cervical cancer screening where the variables that had significance of P-value >0.05 at 95% confidence level were selected and included in the final binary logistic regression model in order to come up with study predictors of cervical cancer screening.
Binary logistic regression model;
p Log i = a + b x + b x + ...... + b x ……………….3.5.1 − 1 1 2 2 i k 1 pi Pi = increased odds of up taking cervical cancer screening (1-pi) = reduced odds of up taking cervical cancer screening bs= array of (X) explanatory or intermediary variables, a= constant coefficient.
3.6 Ethical considerations This study was approved by the Makerere University School of Statistics and Planning and the Directorate of Research and Graduate Training. Participation was voluntary and participants provided written informed consent only after being explained to the study aims, benefits and potential risks. The ethical clearance was obtained from Makerere University directorate of research and graduate training and the investigator received permission from Mukono District Health Officer (DHO) to allow him carry out the study in Mukono municipality.
13
CHAPTER FOUR: STUDY FINDINGS
4.0 Introduction This chapter presents results of characteristics of women (15-49 years) in table 1(one). 4.1 The narrative form of the univariate analysis results The study variables were analyzed and interpretations in narrative form were drawn; the majority of women (n=235, 62%) were single, or divorced. The single or divorced females were more likely to undertake cervical cancer screening than the married women.
The majority of women were Anglican Christians (n=156, 41%) compared to their counterparts. Religious affiliation was considered because different religions have different beliefs about reproductive health issues related with family planning and screening; for example, the Roman Catholic Christians don’t encourage the use of modern contraceptives due to the fear of myths that these methods may result into cancers such as cervical cancer. Islam religion also encourages polygamous marriage which can pose a high risk of contracting and developing the HPV.
The highest level of education was considered in this study because of it’s great influence in changing women’s attitude and increasing their knowledge of cervical cancer screening, thus increasing their ability to undertake cervical cancer screening. The majority (n=211, 55%) of women had no education, or only attained primary level of education.
While as the majority of women (n=222, 58%) were in the lowest wealth quintile, the majority (n=332, 86%) of women resided in rural areas. The women in rural areas are less likely to be positive towards HPV screening due to limited HPV knowledge, and hence are less likely to uptake cervical cancer screening, and the majority of women (80%) stated that household heads were not supportive towards women’s need for HPV screening. In most cases married women are denied permission by their husbands to attend to social groups and health needs. Men in African traditional setting are normally the house hold heads and have authority over their wives (view table 4.1).
The majority (n=158, 41%) of women were of 15-24years. The women’s age was considered due to the influence it has on women’s decision making in seeking reproductive health and their participation in cervical cancer screening programs.
14
Table 4.1: Descriptive analysis of socio-economic, demographic and other factors Variable Classification Frequency Percent (%)
Marital status Single/Divorced 235 62 Married 149 38
Religion Anglican 156 41 Catholic 97 25 Pentecostal/SDA 92 24 Islam 39 10
None/Primary 211 55 Education level Secondary 116 30 Post-Secondary 57 15 Lowest 222 58
Middle 61 16 Wealth quintile Highest 101 26
Rural 332 86 Residence Urban 52 14 15-24 158 41 Age distribution 25-34 116 30 35-44+ 110 29 15-24 146 38 Age at First Sex 25-34 105 27 35-44+ 133 35 <24 164 42 Age At First Marriage 25-38 120 31 39-44+ 102 27 Household head Helpful 185 48 Not helpful 199 52
0 115 30 Parity (Number of 1 Child 101 26 children per woman) 2 children 93 24 ≤3 children 75 20
15
Continuation of the table 4.1
Women’s HPV High knowledge 85 22 Knowledge Low Knowledge 229 78 Positive 92 24 Women’s Attitude Negative 292 76 towards screening
Yes 233 61 Access to Facility No 151 39 Distance to HPV 1>1km 137 36 Screening H. Facility ≤2km 247 64 Health Faculty 173 45 Source of information Media 211 55 Yes 146 38 Ever had HPV No 285 62 Screening
Government Policy Not active 211 56 Active (strict) 95 24 I don’t know 78 20 Respondent’s sex Male 161 42 preference of a health Females 223 58 worker Doctor frequency >Once a year 165 43 Once a year 119 31 16 The findings in the table 4.1 above show that the majority of women (61%, n=233) reported to have had access to the health facility. Although, these women could access the facility, the findings show that the majority of women (64%, n=247) could travel long distance to the health facility. The Majority of women (62% n=285) had never had cervical cancer screening and the majority of women (58%, n=223) preferred female health provider to male ones, and the majority of them (43%, n= 165) visited a doctor less than once a year. Figure 4.1 below shows that the majority of women (about 26%) reported “ignorance about HPV and screening”, as major barrier to HPV screening uptake. Barriers to Cervical Cancer Screning Uptake Among Women (15-49 yrs)-Mukono Municiparity, 216 30 26 25 20 18 18 % of Delays at H.F 15 15 % of High service cost 13 12 % of Ignolence on HPV 10 % of Fear of HPV test 5 % of Health work attitudes % of Scarce services 0 Figure 4.1: Bar graph presenting barriers to cervical cancer screening uptake 17 4.2 Socio-economic, demographic factors with HPV screening uptake Respondents’ age, Parity, AFM, AFS, marital status, residence education level, religion, wealth status, household head’s attribute, knowledge, attitudes, government policy, doctor frequency, medical work sex preference by respondents, source of information, distance to the health facility and access factors were analysed at bivariate level of analysis to determine their association with HPV screening uptake. Table 4.2. Socio-economic, demographic factors with cervical cancer screening uptake Factors P=Value Ever had HPV screening Yes (%) No (%) Age (Years) 0.001 15-24 13 28 25-34 17 13 35-44 + 15 14 Age at First Marriage 0.493 ≥24 18 24 25-38 14 17 ≤39-44 12 23 Age at First Sex 0.150 15-24 15 23 25-34 11 16 ≤35-44 12 23 Parity (No. children per woman 0.114 0 14 16 1 12 14 2 13 11 3+ 10 10 Marital status 0.002 Single/Divorced 29 33 Married 13 25 18 Continuation of table 4.2 Education level 0.000 None/Primary 15 40 Secondary 11 19 Post-secondary 08 07 Wealth quintile 0.000 Lowest quintile 16 42 Middle quintile 8 8 Highest quintile 13 13 Religion 0.000 Anglican 23 18 Catholics 10 15 Pentecostal 12 13 Islam 09 12 House hold head 0.218 Helpful 09 11 Not helpful 44 36 Residence 0.022 Rural 44 56 Urban 33 67 House hold heads’ attributes 0.06 Supportive 27 21 Not supportive 18 34 HPV Scr. knowledge 0.000 High 10 12 Low 33 46 Attitudes 2 HPV screening 0.000 High 39 22 Low 18 21 Distance to HPV screening Facility 0.000 ≥1km 22 14 ≤2km 20 44 19 Extension of table 4.2 Source of Information 0.006 Health facility 19 24 Media 25 30 Doctor frequency 0.080 ≥Once a year 24 19 Once a year 11 20 ≤Once a year 10 16 Government policy 0.296 Not Active 38 18 Active 15 10 I don’t know 10 10 Health work sex preference by respondent 0.067 Male 20 25 Female 32 23 Barriers to HPV screening 0.000 Ignorance 11 15 Fear of the Test 09 09 High service cost 07 11 Delays 06 09 Health workers attitudes 05 07 While as, the majority of women (28%) who had never screened for HPV were from aged 15- 24 years compared to their counterparts (P=0.000), the majority of women (33%) had not regularly taken cervical cancer screening were un married compared to the married (P=0.002, 95% CL). While as, the majority of women (28%) who had never had HPV screening had primary of education compared to their counterparts (P=0.000, 95% CL), the majority (42%) of women who had not been screened of HPV were from the lowest wealth quintile compared to their counterparts (P=0.000) and the majority women (23%) who had ever had cervical cancer screening were the Anglican Christians. 20 While as, the majority of women (67%) who had never been screened of HPV were residents in urban areas compared to their counterparts (P=0.022, at 95% CL), more than a third quarters (46%) of women had ever had HPV screening had low HPV knowledge compared to their counterparts and the majority of women (39%) who had never had HPV screening had low attitudes (P=0.000, P=0.000, at 95% CL). The majority of women (15%) who had never had HPV screening reported “Ignorance about HPV and screening” as a major barrier to HPV screening while the majority of women (22%) who had ever had HPV screening could travel less than a kilometre to the health facility and the majority of women (80%) who had never been screened of HPV relied on the media their major source of information (P=0.006 at 95% CL). 4.3 Factors associated with cervical cancer screening uptake The variables with the significant association (P>0.05) at bivariate level of analysis were subjected to binary logistic regression model in order to assess their relationship with cervical cancer screening uptake. Table 4.3. A Binary Logistic regression (BLRM) to determine predicators Variables Ever Had Cervical Cancer Screening OR (Exp (B) Coefficient (B) P-value Age -0.425 0.002 0.623 Marital status 0.476 0.003 1.610 Wealth status 0.309 0.001 1.362 Education 0.422 0.000 1.525 Religion -0.424 0.001 0.655 Residence 0.313 0.273 1.367 Distance 2 HF 0.193 0.153 1.213 HPV Knowledge 3.508 0.000 33.384 Attitudes -4.243 0.000 0.014 Barriers to Screening -0.341 0.001 0.711 Source of information 0.056 0.452 1.057 Constant -2.839 0.001 0.058 Source: Primary data 21 The study model’ results in Table 4.3, show that women’s age, their marital status, wealth status, women’s knowledge about HPV screening, women’s attitudes towards cervical cancer screening, religion and barriers to HPV screening were significantly related with cervical cancer screening uptake in Mukono Municipality (P=0.002, P=0.003, P=0.001, P=0.000, P=0.000, P=0.001 and 0.001 at 95% Confidence level) respectively. 4.4 Discussion of findings of study based on predictors in the final model This part gives detailed discussion on study predictors in relation to other authors’ findings. 4.4.1The relationship between respondents’ age and HPV screening uptake This study findings show that young women had less odds of undertaking cervical cancer screening (OR=0.62, P=0.002, 95% CL) compared to odder women. The respondents stated that they were too young to contract cervical cancer, therefore, they did see the need to undertake HPV screening. These women hardly seek information on HPV due to many things that take their attention like films, parties and academics which don’t address cervical cancer in the curriculum design yet there are at high risk of developing the cancer due to the fact that this age group is more sexually active than their counterpart. The study findings concur with the findings of Assoumou and Mabika, (2015) which revealed that older women of age 30 years and above had higher likelihood of having higher HPV screening knowledge level. Therefore, it’s important to correct false perceptions women have about cervical cancer through sensitizing young women so as to prevent the development of cancer in their lives once detected through timely, regular screening. This also could be explained in part by the social stigma that is associated with discussing reproductive health with young girls, however this is the age when girls contract the implicated pathogens, thus incorporating cervical cancer education during reproductive lesson into primary school curriculum could have a huge positive ripple effect in the fight against cervical cancer (Waiswa, 2017). 22 However, this study finding is in contrast with the findings of Murungi et al., (2014) which revealed that the older women had lower odds of cervical cancer screening uptake compared to younger women. Older women of age 40 years and above thought they were too aged to undertake HPV screening and therefore, so they could ignore HPV preventive campaigns which could have given them knowledge on HPV and it’s management, Nevertheless, old age has a significant impact on the uptake of cervical cancer screening (Atuhaire, 2013). 4.4.2 Marital status Mukono Municipality study findings show that unmarried women have higher odds of undertaking cervical cancer screening (OR=1.610, P=0.003 at 95% CL) compared to the married ones. Other study findings of Liao et al., (2006) concur with this study findings where he showed that unmarried women had lower odds of up taking cervical cancer screening compared to the unmarried or divorced due to poor attitudes (Liao et al., 2006) which is contrary to the findings of Murungi et al., (2014) which showed no significant association between unmarried and divorced, and uptake cervical cancer screening (P=0.82). 4.4.3 Wealth status with cervical cancer screening uptake Mukono Municipality study shows that females in the highest wealth quintile had higher odds of undertaking cervical cancer screening (OR=1.362, P=0.001, 95% CL) compared to those in the lowest wealth quintile. Ndejjo et al., (2017) concurs with this study by reporting that women in high economic status were more likely to undertake cervical cancer screening (AOR=0.50, P=0.000, 95%) compared to the low-income women in Eastern Uganda. He showed that women who earned more than 40 US dollars per month were 50% more likely to have HPV screening services than their counterparts WHO could earn less than 40 US dollar. In addition, findings of this study concur with findings of Assoumoue et al., (2015) that showed a significant relationship between wealth status, and the likelihood of women to undertake for cervical cancer screening. This is in agreement with the study findings of Twinomujuni et al., (2011) who showed that 11% of the participants lacked the finances to pay for the test and they identified this as the reason they did not go for cervical cancer screening. This highlights the need of providing affordable, or free cervical cancer screening services to increase uptake of the service among women in developing countries (Twinomujuni et al., 2015). 23 4.4.4. Education level with cervical cancer screening uptake The Mukono Municipality study findings show that females with post-secondary education level had higher odds of undertaking cervical cancer screening HPV (OR=1.525, P=0.000, 95% CL) compared to those who had primary level of education or had no education. The study findings also concur with the findings of Muhwezi and Nkomwa, (2016) who showed that higher education level was significantly associated with increased uptake of cervical cancer screening (P=0.001). Women with post-secondary education had higher odds of knowledge on HPV compared to those with primary education level. Sawadogo, (2014)’s findings also are in agreement with Mukono Municipality study findings. He found out that the women with post-secondary education had higher odds of undertaking cervical cancer screening (P=0.001) compared to those who attained primary education or never attained any level of education. 4.4.5 Religion with cervical cancer screening uptake The Mukono Municipality study findings show Muslim women had less odds of undertaking cervical cancer screening (OR=0.66, P=0.001 compared to their counterparts. This finding concurs with the findings of Wilson et al., (2012) which showed that Islam religion was significantly associated with low levels of up taking cervical cancer screening (P=0.001), with Anglican Christian women being the most participants in HPV screening. This in agreement with Ndejjo et al., (2016) who found out those Muslim women had less odds of undertaking HPV screening compared to Christian women. In contrast, Muhwezi et al., (2011)’s study findings showed no significant relationship between religion, and cervical cancer screening uptake (P=0.357). He showed that majority of Christian women had not fully participated in HPV screening due to limited knowledge about the disease and preventive practice. 24 4.4.6 Knowledge level with HPV screening uptake The findings of this study shows that women with high level of HPV screening knowledge had higher odds of undertaking cervical cancer screening (OR=33.38, P=0.000, 95% CL) compared to those who had low knowledge and this is in line with study findings of Ndejjo et al., (2016) which showed that women who knew about one HPV screening test had higher odds of undertaking cervical cancer screening (P=0.002<0.05) compared to those with no knowledge on HPV screening. This concurs with study findings of Lyimo and Beran et al., (2012) among 354 Moshi Tanzanian women (18-69 years). Their findings revealed that more than half (60%) of the participants had a low level of knowledge on cervical cancer and its prevention, thus contributing to a small percentage (22%) of women reported having been screened and he suggested that strong health educative initiatives should be given a priority. In addition, Mukono Municipality finding concurs with findings of Morema and Murungi et al., (2014) among Kisumu women seeking services at the Jaramogi hospital showed knowledge level on the signs and symptoms of cervical cancer was an important determinant of cervical cancer screening among those women. Mukono Municipality study findings concurs with findings of Waiswa et al., (2017) which showed that women who had knowledge on cervical cancer were significantly related with increased likelihood to cervical cancer screening uptake. He showed that out of 63% of women that screened in Oyam district, 35% screened for cervical cancer. In addition, Ndejjo et al., (2016) agreed with this study finding. He showed that rural women who had knowledge of at least one test method for cervical cancer were positively associated with undertaking HPV screening COR=2.88, P=0.002, 95% confidence level). 25 4.4.7 Attitudes towards cervical cancer screening Mukono Municipality study findings show that women with low attitudes towards cervical cancer screening had lower odds (OR=0.014, P=0.000, 95% CL) of undertaking HPV screening compared to those with positive attitudes towards screening of this type of cancer and this is in line with findings of Twinomujuni et al., (2015) which showed that women whose attitudes were positive had higher odds (OR=1.2, P=0.001) of undertaking HPV screening compared to those with poor attitudes towards HPV screening. The respondents in his study stated that respondents who feared the screening procedure had less odds (OR=0.2, P=0.029) undertaking HPV screening compared to those who had no fear. Wong et al., (2010)’s study findings concur with Mukono Municipality study findings. He found out those women who perceived that they were at risk of contracting cervical cancer had higher odds of undertaking cervical cancer screening compared to women whose perceptions disregarded that they were at risk of contracting the cancer of the cervix. 4.4.8 Barriers to cervical cancer screening uptake The study findings show that women who cited “ignorance about HPV” as a major barrier to cervical cancer screening had less odds of cervical cancer screening uptake (OR=0.711, P=0.001, 95% CL) compared to their counter parts who did not have such barriers to screening. Ndejjo et al., (2016) concurs with the above finding where he reported that women who feared the screening procedure had less odds (OR=0.2, P=0.029) undertaking HPV screening compared to those who had no fear. The study gives an in-depth exploration of the barriers that could be limiting most of these females from accessing cervical cancer screening services. The majority of respondents (26%) reported little understanding of the cervical cancer due to lack of information about the disease. Lack of information on the disease and where to access the screening services negatively affects their health seeking behaviours and practices, hence lower the screening rates. 26 CHAPTER FIVE: SUMMARY OF THE FINDINGS, CONCLUSIONS AND RECOMMENDATIONS 5.0 Introduction The discussions of the study findings, conclusions, and recommendations for future research are included in this chapter. 5.1 Summary of the findings This study shows that women with HPV screening knowledge had higher odds of under taking cervical cancer screening (OR=33.4, P=0.000, 95% CL) compared to their counterpart while women with poor attitudes towards cervical cancer screening had less odds of undertaking cervical cancer screening (OR=0.014, P=0.000, 96% CL) compared to those with good attitudes. While as younger women of age 15-24 years had less odds of undertaking cervical cancer screening (OR=0.623, P=0.002, 95% CL) compared to older women, women with post- secondary education had higher odds of undertaking cervical cancer screening (OR=1.525, P=0.000, 95%) compared to those who had no education or had attained primary education level. The women in highest wealth quintile had higher odds of undertaking cervical cancer screening (OR=1.363, P=0.001, 95% CL) compared to those in lowest wealth quintile while unmarried women had higher odds of undertaking cervical cancer screening (OR=1.610, P=0.003, 95% CL) compared to the married ones While as Muslim women had less odds of undertaking HPV screening (OR=0.655, P=0.001, 95% CL) compared to Muslim women, women who reported “ignorance” as a major barrier to HPV screening uptake had less odds of undertaking cervical cancer screening (OR=0.711, P=0.001 compared to their counterparts. 5.2 Conclusion There was low cervical cancer screening uptake (38% of women reported). Older women, the women in first wealth quintile, Anglican Christian, Post-secondary educated women, unmarried women, HPV knowledgeable women, women with good attitudes towards HPV screening and those who mentioned “delays at health facility “as a major barrier were more likely to undertake cervical cancer screening than their counterparts. 27 5.3 Recommendations The study recommends that the government and other humanitarian organization should strengthen sanitization campaigns that would enhance women’s knowledge about cervical cancer and screening. The government in conjunction with the Ministry of health should integrated affordable HPV screening programmes in other strategic health priority programs such as anti-HIV/AIDS, Malaria campaigns and the HPV screening programs should be incorporated in Uganda’s educational curriculum. And government policy and guidelines should be revised in order to prioritize cervical cancer screening programs among other health programs that are intended to reduce women mortality. 5.4 Recommended studies by the researcher The following studies are recommended areas for further investigation; Barriers in accessing HPV vaccination among the young girls aged 9-13 years” A case studies of Mukono District, “Prevalence of cervical cancer (HPV) among women in the reproductive age in Mukono district”, and “the assessment of men’s role on females’ accessibility to cervical cancer screening services in Mukono municipality” should be thought about by researchers in the academia for further investigation. 28 REFERENCES Abotchie PN, Shokar NK. (2009). cervical cancer screening among college students in Ghana: knowledge and health beliefs. International Journal of Gynecological Cancer, 19 :412-416. Andersen RM. Revisiting the behavioural Model and access to medical care: does it matter? Health Soc Behav 1995; 36 (March): 1-10. Al-Naggar, R. A., Low, W. Y., & Isa, Z. M. (2010). Knowledge and barriers towards cervical cancer screening among young women in Malaysia. Asian Pacific Journal of Cancer Prevention , 11 (4), 867–873. Ali, S. F., Ayub, S., Manzoor, N. F., Azim, S., Afif, M., Akhtar, N., Uddin, N. (2010). Knowledge and awareness about cervical cancer and its prevention amongst interns and nursing staff in tertiary care hospitals in Karachi, Pakistan. PLoS ONE , 5(6), 1–6. http://doi.org/10.1371/journal.pone.0011059 Arrossi, S., Paolino et al, M., & Rengaswamy,S. (2010). Challenges faced by cervical cancer prevention programs in developing countries: a situational analysis of program organization in Argentina. Revista Panamericana de Salud Publica/Pan American Journal of Public Health Asiimwe, S., Whalen, C. C., Tisch, D. j, Tumwesigye, E., &Sethi, A. K. (2010). Prevalence and predictors of high-risk human papillomavirus infection in a population-based sample of women in rural Uganda. National Institutes of Health , 19 (9), 605–610. http://doi.org/10.1258/ijsa.2008.008025.Prevalence Assoumou, S. Z., Mabika, B. M., Mbiguino, A. N., Mouallif, M., Khattabi, A., Bukirwa, Mutyoba, Karamagi, & Ennaji, M.M. (2015). Awareness and knowledge regarding of cervical cancer, Pap smear screening and human papillomavirus infection in Gabonese women. BMC Women’s Health , 15 (1), 37. http://doi.org/10.1186/s12905-015-0193-2 Atuhaire, L. (2013). Barriers and facilitators to uptake of cervical cancer screening among women accessing Maternal and Child Health services in Kampala , Uganda, (September). Bajunirwe, F., & Muzoora, M. (2005). Barriers to the implementation of programs for the prevention of mother-to-child transmission of HIV: a cross-sectional survey in rural and urban Uganda. AIDS Research and Therapy , 2, 10. http://doi.org/10.1186/1742-6405-2-10 Belete, N., Tsige, Y., Mellie, H., Sam, M., Kishor, B., Clement, A., Buziba, N. (2015). Willingness and acceptability of cervical cancer screening among women living with HIV/AIDS in Addis Ababa, Ethiopia: a cross sectional study. Gynecologic Oncology Research and Practice , 2(1), 6. http://doi.org/10.1186/s40661-015-0012-3 Bukirwa, A., Mutyoba, J. N., N Mukasa, B., Karamagi, Y., Odiit, M., Kawuma, E., &Wanyenze, R. 29 K. (2015). Motivations and barriers to cervical cancer screening among HIV infected women in HIV care: a qualitative study. BMC Women’s Health , 15 (1), 82. http://doi.org/10.1186/s12905-015-0243-9 Campos N.G., Tsu V.,Jeronimo J.,Myundura M., Lee K., Kim J.J. To expand coverage, or inrease frequency:quantifying the tradeoffs between equity and efficiency facing cervical cancer screening programs in low-resource settings. Int.J.Cancer.2016 (Epub ahead of print)[PubMed] Chakravarty,(2014): Amita & Pauline, (2015). Factors Associated with the Uptake of Cervical Cancer Screening Among Women in Portland, JamaicaN Am J Med Sci. 2015 Mar: 7(3):104-113. doi: [10.4103/1947-2714.153922] PMCID: PMC4382764 Chakravarty, J., Chourasia, A., Thakur, M., Singh, A. K., Sundar, S., & Agrawal, N. R. (2016). Prevalence of human papillomavirus infection & cervical abnormalities in HIV-positive women in eastern India. Indian Journal of Medical Research , 143 (JANUARY), 79–86. http://doi.org/10.4103/0971-5916.178614 Chumnan, Kriangsak, Usanee, S., Jatupol, S. (2009).Knowledge, awareness, attitudes of female sex workers toward HPV infection, cervical cancer, and cervical smears in Thailand. Int J GynecolObstet; 107:216–9 Denny, L., Quinn, M., & Sankaranarayanan, R. (2006). Chapter 8: Screening for cervical cancer in developing countries. Vaccine , 24 (SUPPL. 3). http://doi.org/10.1016/j.vaccine.2006.05.121 Fylan, F. (1998). Screening for cervical cancer: a review of women’s attitudes, knowledge, and behaviour. The British Journal of General Practice , (March), 1509–1514. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313202/ Gakidou, E., Nordhagen, S., & Obermeyer, Z. (2008). Coverage of cervical cancer screening in 57 countries: Low average levels and large inequalities. PLoS Medicine , 5(6), 0863–0868. Jia, Y., Li, S., Yang, R., Zhou, H., Xiang, Q., Hu, T., Feng, L. (2013). Knowledge about Cervical Cancer and Barriers of Screening Program among Women in Wufeng County, a High- Incidence Region of Cervical Cancer in China. PLoS ONE , 8(7), 2–8. http://doi.org/10.1371/journal.pone.0067005 Lukorito J., Wanyoro, Kimani H. (2017). Uptake of Cervical Cancer Screening among HIV Positive Women in Comprehensive Care Centres in Nairobi, Kenya. Research in Obstetrics and Gynecology, 5(1): 1-6 DOI: 10.5923/j.rog.20170501.01 Lymo S. F., Beran N.T., (2012). Demographic, knowledge, attitudinal, and accessibility factors associated with uptake of cervical cancer screening among women in a rural 30 district of Tanzania: Three public policy implications. BMC Public Health , 12:22 http://www.biomedcentral.com/1471-2458/12/2. Morema, E. N., Atieli, H. E., Onyango, R. O., Omondi, J. H., & Ouma, C. (2014). Determinants of cervical screening services uptake among 18-49 year old women seeking services at the Jaramogi Oginga Odinga Teaching and Referral Hospital, Kisumu, Kenya. BMC Health Services Research , 14 , 335. http://doi.org/10.1186/1472-6963-14-335 Mukama, T., Ndejjo, R., Musabyimana, A., Halage, A. A., & Musoke, D. (2017). Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in Eastern Uganda. BMC Women’s Health , 17 (1), 9. http://doi.org/10.1186/s12905-017-0365-3 Mukono District Health report, (2016). A statistical report at the health Centre IV Mukono District, Ministry of Health-Uganda. Ndejjo, R., Mukama, T., Musabyimana, A., & Musoke, D. (2016). Uptake of cervical cancer screening and associated factors among women in rural Uganda: A cross sectional study. PLoS ONE , 11 (2), 1–13. http://doi.org/10.1371/journal.pone.0149696 Peter N. Abotchie, Mp. and, Center for Health Promotion &, Prevention Research, University of Texas School of Public Health, 7000 Fannin, Ste. 2510E, Houston, TX 77030, U., Navkiran K. Shokar, M. M. M., & Dept of Family Medicine, The University of Texas Medical Branch, Galveston, Texas, U. (2010). Cervical Cancer Screening Among College Students in Ghana: Knowledge and Health Beliefs. Int J Gynecol Cancer. , 19 (3), 412–416. Robertson, N., Winston, S., Miller, K., & Hanebrink, J. (n.d.). Cervical Cancer Infrastructure, Knowledge and Attitudes in Kabale , Uganda, 4. Rositch, A. F., Gatuguta, A., Choi, R. Y., Guthrie, B. L., Mackelprang, R. D., Bosire, Farquhar, C. (2012). Knowledge and acceptability of Pap smears, self-sampling and HPV vaccination among adult women in Kenya. PLoS ONE , 7(7). Singh KK, Bloom SS, Tsui AO, (1998). Husbands’ reproductive health knowledge, attitudes, and behavior in Uttar Pradesh, India. Studies in Family Planning 1998, 29:388-399. Twinomujuni, C., Nuwaha, F., & Babirye, J. N. (2015). Understanding the low level of Cervical cancer screening in Masaka Uganda using the ASE model: A community-based survey. PLoS Wabinga, H., Ramanakumar, A. V, Banura, C., Luwaga, A., Nambooze, S., & Parkin, D. M. (2003). Survival of cervix cancer patients in Kampala, Uganda: 1995-1997. British Journal of Cancer , 89 (1), 65–9. http://doi.org/10.1038/sj.bjc.6601034 Wabinga, Waiswa, H.,Kahesa C., Mwaiselage J,Ngoma T, Kalyango JN, Karamagi C., 31 (2008).Association between invasive cancer of the cervix and HIV-1 infection in Tanzania: the need for dual screening. BMC Public Health 2008, 8(1):262. . Wilson, M., Banula, C., & Bunjo, K. T. (n.d.). TR-16-139 DISTRIBUTION STATEMENT A: Approved for public release; distribution is unlimited. -1-, 1–13. Wong, L. P. (2011). Knowledge and attitudes about HPV infection, HPV vaccination, and cervical cancer among rural Southeast Asian Women. International Journal of Behavioral Medicine , 18 (2), 105–111. http://doi.org/10.1007/s12529-010-9104- 32 APPENDIX 1: Cervical cancer screening Study Household tool, 2016 TIME STARTED Questionnaire Number ……………………...... Name of the Village ...... Guidance notes for introducing yourself and the purpose of the interview o Greet the interviewee according to the local culture of the area o My name is______and am doing work for Chris Byaruhanga’s academic research project as a fulfillment of Master’s Degree in Reproductive Health, Makerere University, student’s Registration number; 2014/HD06/1946U. Your Household has been selected by chance from all households in the area for this interview. The purpose of this interview is to obtain information on factors that influence the knowledge and attitudes towards cervical cancer screening among the females in the reproductive age in Mukono Municipality. The survey is voluntary and the information you give will be confidential. o Could you please spare some time (around 45 minutes) for the interview How many years have you consistently been staying in this settlement? …………………… 100: Back ground characteristics (Circle the appropriate response) 101 Name of Respondent ………………………………………………. 102 Ward/sub county’s name. …………………………………….. ………. 103 Parish’s name...... 104 Village’s name ...... 105 What is the highest level of education among 0. None 1. Primary, 2. O’ level, 3. A’ Level, 4.Post A’ household members of the household? level , 5. University 106 What is the least level of education among the (use the above codes) household head? 107 Age of Respondent. (Full completed years) ...... 108 How old were you when you had first birth? ...... 109 How old were you when you had first marriage? ……………………………………………….. 110 How many biological children (>5) do you ……………………… have? 33 111 Marital status of Respondent. 1.Single 2.Married 3.Separated/Divorced 4.Widowed 5. Others (specify) ………………. 112 Highest education level attained by Respondent. 1.None 2.Incomplete Primary 3.Complete Primary 4.Secondary 5. Post-Secondary 6.Others specify...... 113 What activity are you currently doing? 1.None 2.Farming 3.Trading 4.Salaried employment 6.Casual work 5. Artisan 6.Other (specify) ………………. 114 How many people live in this household? …………………………………...... 115 Respondent’s Religion 1. Anglican 2. Cat holic 3. Pentecostal. 4. Islam 4. SDA 5. Others (specify...... ). 2. 116 How many chil dren do you have so far? …………………………………….. 117 Does your husband (household head) support 1. Yes you in accessing screening services 2. No 200 Socio-economic (during last seven days) 201 On average, how many people were present in Adults____ 1. One adult 2.Two adults 3, 3-4 adults the last 7 days? 202 How much on average did you spend on food ------in last week? 203 Do you consume alcohol or smoke? If yes 0. Yes 0.No 204 What is your household most source of 1. Agribusiness 2.Machidise business 3.Wage income? Employment 4.Self-employment 5. Transfers(pensions, allowances) 6.Others 205 What was the household's income from crop ______farming enterprises during the last year? 206 How often did the household eat meat or fish 1. Once 2. Twice 3.thrice 4.daily 5. in the last week? others(specify)______ 207 What is the average number of meals taken by 1. One meal 2.two meals 3. Meals household members per day in the last 7 days? 4. Four meals 5. others(specify) 208 What did you do when you last ran out of salt? 1. Borrowed from neighbors 2. Did without 3. Bought 34 209 Did every member of the household consume 1. Yes all 2.Children only 3.Adults only sugar during the last 7 days/week? 4.None b) Household Property/Assets /enterprise 213 Which of these items does your household 1. Car 2. Motorcycle , 3.Bicycle, 4.Radio own?(circle the items possessed in the 5. Tv. 6.Sofa set 7. Fridge 8.Sideboard 9.Phones 10. household) Mattress 11. Beds 214 What is your house own ship status? 1.Rent 2.My own house 3.for friend 4 others 215 If you own the house, what is its status? 1. Temporary house 2.Semi - permanent 3. Permanent 4. Hut 0thers(specify)______ 216 Were there any enterprise activities in the past 5 Yes =1, No = 2 years that are no longer running? d) Utilities 219 What type of water source do you use? 1. Public Tapped water on sale 2. Tapped inside the house/ home/gravity 3. Community spring/well 4. River/lake 5. Others(specify)______ 220 What do you use for lighting at night in your house? 1. Electricity 2.Lamp 3.Candled 4. Torch 5.Fire from wood 6.Others(specify)______ 221 Do your husband participate in supporting you to go for medical 1 Yes 0.No 3. Some times checkups/or screening? 222 If no, what hinders hime to support your health medical care? 1.Women determine priorities of home needs 2.Men fear 3.They are busy 4.Ignorant/not informed by wife 5.Others. 223 How safe is your household from crime and Don’t Know = 1 Very Unsafe= 2 Neither Safe nor violence? Unsafe= 3 Generally Safe= 4 Very Safe= 5 e) Social leadership 224 Is any member of this household an LC1, LC2, Yes = 1 , No = 2 or LC3 committee member? 225 Do you or any ot her household member have Yes = 1 , No = 2 close relations with LC2 or LC3 chairman/chief 300 Respondent’s knowledge and attitudes(willingness, not ) towards cervical cancer screening 35 301 Do you understand the cervical cancer? 1. Yes 2. No 301.2 Women’s attitudes to HPV screening 0. Negative 1. Positive 302 The following may increase a woman’s chance 1) Unprotected sex with multiple of developing cervical cancer. How much do partners you agree? ( Fill the opposite blank space 2) Drug addiction with code of appropriate response). 3) Infections 1. Strongly 2. Disagree 3.Disagree Not 4.Sure 5. Agree Strongly 6. Agree 4) Poor nutrition/diet 5) Having many Children(>5) 6) Not going for regular (smears) Pap tests. 7) Long term use of contraceptives 8) Weakened immunity due to i.e., HIV/AIDS 9) Starting to have sex at early age (like at 17years) 10) Having uncircumcised sexual partner 11) Others(specify) 203 The following may be warning signs for cervical a) Pain in the abdomen cancer. I am interested in your opinion; 0. No 1. Yes 2. Don’t Know b) Pain in the vagina c) Pain during passing urine d) Pain during sex e) Diarrhea f) Unexplained loss of weight g) Blood in the stool or urine h) Vaginal bleeding after menopause i) Bleeding j) Bleeding between periods k) a persistent smelly vaginal discharge l) Long menstruation periods than usual 400: Responses on health facility characteristics/the practice 36 304 When you had a symptom that you thought 1. Visited a medical doctor 2. Herbalist 3. might be a sign of cervical cancer, what did you do? Spiritual healing 4. Ignored 5 can’t remember 6. Others (specify……….) 305 How much do you pay for the treatment ...... (Ugx) materials? 306 Have you ever had about cervical cancer 0. Yes 0.No screening? 307 If, yes What is your main source of information 1. Local women’s groups about cervical cancer screening hygiene ? [ one 2. Places of worship (church/mosque) answer only] 3. Health facilities 4. At home 5. Markets 6. Media (eg, TV, Radio…..) 7. Others (Specify)………………… 308 How many times should one go for cervical 1. Once 2. Twice 3. Thrice 4.Others cancer screening? (specify...... ) 309 A woman age < 40 does not need to go for 1. Strongly Agree 2. Agree 3. Not sure cervical cancer screening. 4. Disagree 5 Strongly agree. 310 The female above 60 years should not go for 1. Strongly Agree 2. Agree 3. Not sure 4 . cervical cancer screening. Disagree 5 Strongly agree. 401 Do you have a health facility or screening points 0. No 1. Yes in your community 402 What is the distance to health facility ? 1. Near (Less than 200 M) 2. Not Far (200-500m) 3. Far (500m-1km) 4. Very Far (More than 1km) 403 Are you willing to go for cervical cancer 0. Not willing 1. willing Outco screening at any accessible reliable, health me facility? variabl e 404 If, No what factors do you consider as 1. Poor attitude of nurses hindrances to go for Cervical cancer screening 2. Delays at health point services? Circle more than one answer as 3. Its expensive provided by the respondent). 4. Don’t see symptoms/signs 5. Just don’t want 6. Fear medical screening procedure. 37 7. Others 405 If yes, do you think there is cervical cancer 1. Yes 2.No screening service in your nearby health facility? 406 How much time does it take you from your home to where you can access cervical cancer screening Centre or point/facility?(to and fro) In minutes …………………………… 407 Which sex of nurses do you prefer to facilitate you in screening cervical cancer? 1. Male 2. Female 408 How do you rate the health workers willingness 1. Not willing 2. Very willing 3 Fairly willing to screen the clients for cervical cancer? 4. Others (specify). 409 Have you been having regular cervical cancer 0. Never been screened screening or not? 1. Ever been screening 410 In last year, how many times did see a doctor for 1. Less than Once /year cancer screening? 2. Once a year 3. More than once/year 410 (b) are government policy and guidelines support 1. Yes HPV screening practices in your place? 2.. No 3. I don’t know 411 In the last two weeks, have health workers 1. Yes 2. No 3. Don’t know sensitized about the cervical cancer screening? 412 What do you consider are the factors that 1. Financial ability 2. Nurse attitudes 3. determine the willingness to go or not for Education 5. Distance to health facility 6. Age cervical cancer screening? at first marriage 7. Others 413 Approximate the amount of money do you ...... (Ugx) anticipate to pay for your medical bill at your nearby health facility? 500: Other Socio -economic factor affecting the willingness of respondents to have screening 501 Women of low social position in community 1.Strongly agree 2.Agree 3.Not sure can’t motivation to access cervical cancer screening? 4.Disagree 5.Strongly disagree 502 Some of HIV infected Women fear 1.Strongly agree 2.Agree 3.Not sure stigmatization, being isolated due to cervical 4.Disagree 5.Strongly disagree 38 cancer so they are not willing to go for Cervical cancer screening 503 There is something wrong if the community has 1.Strongly agree 2.Agree 3.Not sure a negative attitude towards those who have cervical 4.Disagree 5.Strongly disagree 504 Prejudice and other Barriers are the main 1.Strongly agree 2.Agree 3.Not sure problems that affect some women’s willingness to go for screening of cervical cancer? 4.Disagree 5.Strongly disagree 505 Women who are not socially involved in social 1.Strongly agree 2.Agree 3.Not sure groups will no willingness boost to test for cervical? 4.Disagree 5.Strongly disagree 506 Females who can’t access public media 1.Strongly agree 2.Agree 3.Not sure platforms, listen to news, chat on internet messaging linkages may not be aware about the 4.Disagree 5.Strongly disagree cancer signs, symptoms and cervical cancer screening? 507 Females with lowest levels of education primary 1.Strongly agree 2.Agree 3.Not sure will not be willing to go for cervical screening compared to the highly educated 4.Disagree 5.Strongly disagree 507 Young females can’t be willing to go for 1.Strongly agree 2.Agree 3.Not sure screening of cervical. 4.Disagree 5.Strongly disagree 508 Females residing in Urban/towns will be more 1.Strongly agree 2.Agree 3.Not sure willing to test for cervical than those in village? 4.Disagree 5.Strongly disagree 509 Barriers to access cervical c ancer screening bring 1.Strongly agree 2.Agree 3.Not sure negative attitude of females to go for screening. 4.Disagree 5.Strongly disagree 510 Can females go for screening suppose the 1.Strongly agree 2.Agree 3.Not sure barriers are removed and with support or equipment if necessary? 4.Disagree 5.Strongly disagree 511 Females from the first and second wealth 1.Strongly agree 2.Agree 3.Not sure quartile are more knowledgeable about the cervical cancer willing to go for screening. 4.Disagree 5.Strongly disagree D Field Interviewer: Name …………… …Date ………………….. Supervisor: Name …………………… ...Date ………………… TIME OF COMPLETION 39 APPENDEX 2: Declaration of Originality Form DECLARATION OF ORIGINALITY FORM MAKERERE UNIVERSITY Declaration of Originality Form Name of Student…………………………………………………………………………. Registration Number………………………………………………………………………. University……………………………………………………………………………………. Faculty/School/Institute…………………………………………………………………….. Department…………………………………………………………………………………. Course Name……………………………………………………………………………….. Title of work………………………………………………………………………………… DECLARATION I understand what Plagiarism is and I am aware of the University’s policy in this regard I declare that this………………………. (Thesis, project, essay, assignment, paper, report, etc) is my original work and has not been submitted elsewhere for examination, award of a degree or publication. Where other people’s work or my own work has been used, this has properly been acknowledged and referenced in accordance with the University requirement. I have not sought or used the services of any professional agencies to produce this work. I have not allowed, and shall not allow anyone to copy my work with the intention of passing it off as his/her own work. I understand that any false claim in respect of this work shall result in disciplinary action, in accordance with University Plagiarism Policy. Signature of student Signature of supervisor …………………………….. …………………………… Date: …………………….……… ………………………….. 40 APPENDIX 3: Researcher’s statement STATEMENT BY THE RESEARCHER I confirm that the participant was given an opportunity to ask questions concerning the study, and all the questions asked by the participant have been answered correctly and to the best of my ability. I confirm that the individual has not been coerced into giving consent, and the consent has been given freely and voluntarily. Name of researcher…………………… Signature……………………Date ……/……/………. 41 APPENDIX 4: Introduction Letter 42 APPENDEX 5: A Map of Mukono District 43