The result highlighted below using the Health Belief Model (HBM) proposed by Rosenstock (1966)[27], explained, and predicted the likely behavior of African women towards the uptake of cervical cancer screening services.
Socio-demographic characteristics of Respondents
There were more Masters’ students (87.9%) represented than the rest such as Ph.D. (8.9%), MPhil/Ph.D (1.9%), etc. The age range was between 20-52 years with a mean age of 27.3 ± 5.4. The majority (80.3%) were young adults aged 20-29 years, others who were between 30-39 years and 40-49 years constituted 13.9% and 5.1%, respectively. Most (89.8%) were single while 9.9% were married.
Sexual and Reproductive Health Experiences and Vulnerability among Respondents
When asked the question “ever had sex” almost half (49.5%) of the respondents stated ‘Yes’ while 50.5% said ‘No’. The age at first sex ranged from 8-33 years with a mean of 21.6±4 years. A majority (73.3%) had sex first when they were within the age range of 15-24. 13.5% said they could not disclose their age at first sex. Only 9.4% of respondents had ever taken oral contraceptives while 1.3% has a family member who had CC. More details are shown in Table 1.
Table 1: Respondents’ sexual and reproductive health experiences
Reproductive and Sexual experiences
|
No
|
%
|
Ever had sex (N= 372)
|
|
|
Yes
|
184
|
49.5
|
No
|
188
|
50.5
|
Age at first sex* (n= 105)
|
|
|
5-14
|
6
|
5.7
|
15-24
|
77
|
73.3
|
25-34
|
22
|
21
|
(*Mean age at first sex = 21.6±4, Median = 22, Mode = 20,
Range = 8-33)
|
Other responses (n=267)
|
|
|
Never had sex/NA
|
188
|
70.4
|
I cannot remember
|
12
|
4.5
|
I cannot say/disclose
|
66
|
24.7
|
Raped
|
|
0.4
|
Ever taken oral contraceptives n= 371
|
|
|
Yes
|
35
|
9.4
|
No
|
336
|
90.6
|
Family member with a history of cervical cancer N= 372
|
|
|
Yes
|
5
|
1.3
|
No
|
367
|
98.7
|
Relationship with this family member with a history of cervical cancer n= 5
|
|
|
Cousin
|
2
|
40
|
Mother’s sister
|
1
|
20
|
Father’s sister
|
1
|
20
|
Mother’s cousin
|
1
|
20
|
Perception Towards Cervical Cancer and Cervical Cancer Screening
Most (70.4%) disagreed that CC is a mild disease while 35.8% were undecided about CC leading to infertility. 12.4% agreed that cervical cancer occurs in people who are sexually active. See Table 2a for more details
Most (73.4%) disagreed that CCS is only for married women. 50.5% agreed that the benefits of CCS outweigh the stress of the screening procedure. More details on the respondents’ perceptions are shown in Table 2b below.
Table 2 (a-b): Respondents’ perception relating to Cervical Cancer and Cervical Cancer Screening N= 372
a) Perception towards Cervical Cancer
|
Agree
|
Disagree
|
Undecided
|
Cervical cancer only occurs in people who are
too sexually active
|
46 (12.4)
|
165 (44.4)*
|
161 (43.3)
|
Cervical cancer is a mild disease
|
12 (3.2)
|
262 (70.4)*
|
98 (26.3)
|
Cervical cancer screening can lead to infertility
|
101 (27.2)
|
138 (37.1)*
|
133 (35.8)
|
Cervical cancer occurs only in people who do
not know God
|
6 (1.6)
|
273 (79.8)*
|
93 (18.5)
|
b) Perception towards Cervical Cancer
Screening
|
Agree
|
Disagree
|
Undecided
|
|
Cervical cancer screening is a waste of time; it doesn’t stop it from killing someone
|
6 (1.6)
|
273(73.4)*
|
93 (25.0)
|
|
Cervical cancer screening is only for married women
|
9 (2.4)
|
273 (73.4)*
|
90 (24.2)
|
|
Pap smear test procedure is too discomforting
|
50 (13.4)
|
74 (19.9)*
|
248 (66.7)
|
|
The benefits of Cervical cancer screening outweigh the stress of the screening procedure
|
188 (50.5)*
|
35 (9.4)
|
149 (40.1)
|
|
*favourable perception
The Pattern of Utilisation of Cervical Cancer Screening
Only 4% of the respondents have been screened for CC. Their commonly mentioned motivating factor for undergoing the CCS test was the “rate of the increase of CC” (15.89%). Other factors mentioned included “being part of HIV testing” (10.5%), and “done routinely” (10.5%).
Among those that have ever been screened, 46.7% stated that they had been screened in the last 3 years. Pap smear test was the most (53.8%) mentioned type of CCS test received. Only 7.7% of the respondents who had been screened reported that the outcome of the screening test was positive as shown in Table 3.
Table 3: History of involvement in cervical cancer screening test among respondents
History of involvement in cervical cancer screening test
|
N
|
%
|
Ever been screened for cervical cancer (N= 372)
Yes
No
Cervical cancer screening motivating factors (n=20)*
My aunt
Wedding preparation
Church advice
It was free
Part of HIV testing
Because it killed Dora Akunyili
A lot of information in the newspaper
Done routinely and officially
Seminar
Curiosity/to be sure am not infected
Initiated by the employer in the office
Rate of increase/ dangers of cervical cancer
A friend’s advice
Part of medical checkup
Ever been screened for cervical cancer in the last 3 years (n= 15)
Yes
No
|
15
357
1
1
1
1
2
1
1
2
2
1
2
3
1
1
7
8
|
4.0
96
5
5
5
5
10
5
5
10
10
5
10
15
5
5
46.7
53.3
|
Number of times screened for cervical cancer within the last 3 years (n= 7)
Once
Two times
|
5
2
|
71.4
28.6
|
Place where last cervical cancer screening test was conducted (n=13)
Teaching hospitals
Government hospital
A private hospital/clinic
Health programme in school
Workplace/office clinic
Church
|
3
1
5
1
2
1
|
23.1
7.7
38.5
7.7
15.4
7.7
|
Type of cervical cancer screening test received (n=13)
Visual inspection
Pap smear test
Human papillomavirus (HPV) testing and pap smear
Don’t know
|
2
7
1
3
|
15.4
53.8
7.7
23.1
|
Outcome of the cervical cancer screening test (n = 13)
Positive
Negative
|
1
12
|
7.7
92.3
|
*multiple responses
Service Delivery Preferences Relating to the Adoption of Cervical Cancer Screening
Most respondents (86.3%) expressed their desire to be screened for CC if given the opportunity. The most preferred place for the screening mentioned was teaching hospitals (60.7%). Some mentioned “anywhere” (2.2%), and any available hospital (0.9%) as their most preferred places. Among the health professionals who preferred to conduct the screening, female doctors 73.2% topped the list followed by any skilled health personnel (20.6%). Some mentioned male doctors (4%) and male nurses (0.3%) as their preferred health professionals as depicted in Table 4.
Among the list of preferred CCS service delivery options, most (70.7%) said “inclusion of CCS test during an antenatal clinic visit, 65.9% said “walk-in clinics in the hostel where CCS is done” while 64.2% said they preferred “rendering of CCS services in religious centres/institution”. The least preferred option mentioned was the inclusion of a CCS test during student entrance medical examination as also shown in Table 4.
Table 4: Cervical Cancer screening-related intentions and preferences among respondents
Cervical Cancer screening related intentions and preferences
|
No.
|
Percent (%)
|
Desire to be screened for cervical cancer if given the opportunity (N= 372)
Yes
No
|
321
51
|
86.3
13.7
|
Place where respondents would like to be screened (n= 321)
Teaching hospital
Jaja clinic
Government hospital
A private hospital
Air force hospital
A hospital with experienced personnel/equipment for the test
Any available hospital
Anywhere
Private standard labouratory
|
195
33
29
44
2
7
3
7
1
|
60.7
10.3
9.0
13.7
0.6
2.2
0.9
2.2
0.3
|
Health professionals preferred to conduct the cervical cancer screening ( n = 321)
Female Doctor
Male doctor
Female nurse
Male nurse
Any skilled health personnel
|
235
13
6
1
66
|
73.2
4.0
1.9
0.3
20.6
|
Preferred cervical cancer screening service delivery options
N = 372
|
Yes (%)
|
No (%)
|
Inclusion of Cervical Cancer Screening test during antenatal visit
|
263 (70.7)
|
109 (29.3)
|
Inclusion of Cervical Cancer Screening test during HIV testing and counseling
|
225 (60.5)
|
147 (39.5)
|
Inclusion of Cervical Cancer Screening test during student entrance medical examination
|
167 (44.9)
|
205 (55.1)
|
Provision of “walk-in” clinics in the hostels where Cervical Cancer Screening test is done
|
245 (65.9)
|
127 (34.1)
|
Rendering Cervical Cancer Screening services in religious centres
|
239 (64.2)
|
133 (35.8)
|
Motivation to Utilise Cervical Cancer Screening
In Table 5, most respondents (68.8%) stated that they will go for CCS once they have good knowledge of what it entails while 56.5% were willing to use CCS service once the doctor recommends it. More than half of the respondents (56.5%) also disagreed with the statement that they would not go for CCS because they cannot have CC. Slightly more than half of the respondents (53.8%) were undecided about using CCS services no matter the cost while 46.8% were also undecided about obtaining the services without their husbands’ consent.
Table 5: Perceived factors that would motivate respondents to utilise Cervical Cancer screening services (N = 372)
Perceived factors that would motivate respondents
|
Yes
|
No
|
Undecided
|
I will go for Cervical Cancer Screening once I have good knowledge of what it entails
|
265 (68.8)
|
32 (8.6)
|
84 (22.6)
|
I will not go for Cervical Cancer Screening because I do not see the need for it
|
22 (5.9)
|
225 (60.9)
|
125(33.6)
|
I am ready to use Cervical Cancer Screening services no matter the cost
|
102 (27.4)
|
70 (18.8)
|
200 (53.8)
|
I will go for Cervical Cancer Screening once I see someone who has cervical cancer
|
18 (4.8)
|
220 (59.1)
|
134 (36.0)
|
I will not go for Cervical Cancer Screening because I cannot have cervical cancer
|
28 (7.5)
|
210 (56.5)
|
134 (36.0)
|
I am willing to use any Cervical Cancer Screening services once my doctor recommends it
|
210 (56.5)
|
38 (10.2)
|
124(33.3)
|
I will not go for Cervical Cancer Screening without the consent of my husband
|
88 (23.7)
|
110(29.6)
|
174 (46.8)
|
Experiences relating to Sexually Transmitted Infections (STIs), Sexual partners, and patterns of condom use
On the question on sexual partnership, 17.8% stated that they currently have one male friend they have sex with while 2.2% said they have more than two male friends. Only 27.7% of the respondents had used condoms, more than half (61.2%) used it rarely while 36.9% used it always. About 55.3% used condoms during the last sexual intercourse as depicted in Table 6.
Table 6: Respondents’ experiences relating to Sexually Transmitted Infections (STIs), Sexual partners, and patterns of condom use
Experiences relating to Sexually Transmitted Infections (STIs), Sexual partnership, and patterns of condom use among respondents
|
No.
|
Percent(%)
|
Number of sexual partners currently have sex with (n= 371)
|
|
|
None
|
297
|
80
|
1
|
66
|
17.8
|
More than 1
|
8
|
2.2
|
Ever used condom(N=372)
|
|
|
Yes
|
103
|
27.7
|
No
|
269
|
72.3
|
Type of condom used (n=103)
|
|
|
Male condom
|
95
|
92.2
|
Female condom
|
8
|
7.8
|
Frequency of condom use (n=103)
|
|
|
Always
|
38
|
36.9
|
Rarely
|
63
|
61.2
|
Whenever my partner wants it
|
2
|
1.9
|
Use of condom during the last sexual activity (n=103)
|
|
|
Yes
|
46
|
44.7
|
No
Ever had sexually transmitted infections (N= 372)
|
57
|
55.3
|
Yes
|
7
|
1.9
|
No
|
365
|
98.1
|
Types of sexually transmitted infections ever experienced (n=6)
|
|
|
Candidiasis
|
3
|
50
|
Staphylococcus
|
2
|
33.3
|
I cannot remember
|
1
|
16.7
|
Age when had sexually transmitted infections* (n= 6)
|
|
|
15-19
|
1
|
16.7
|
20-24
|
4
|
66.6
|
25-29
|
1
|
16.7
|
*Mean age when had STI = 22.2±3.8, Median = 21.5, Mode = 18a, Range = 18-29. a. multiple modes exist. The smallest value is shown
|
|
|
Association between sexual activity and cervical cancer screening behaviours
Statistical analyses, based on the Pearson square Chi-2 test showed a significant association (p.value=0.0007) between CCS behaviors and sexual activity among women. Results further underscore that the underlying relationship was remarkably high (Yule coefficient = 0.71 >0.70). Indeed, slightly less than one sexually active woman (ever had sex) in every ten (8.94%) have been screened at least once. Among those who never had sex only 1.60% have been tested at least once. The Odds Ratio of 6.02 shows that sexually active women were six times more likely to develop a pattern of CCS relative to non-sexually active women. Since the 95% confidence interval value of the Odds Ratio does not include the value one, it can be concluded that this value is statistically significant: meaning that it is not likely that the recorded association is due to chance. Table 7 below presents more details on the relationship.
Table 7: Relationship between sexual activity and patterns of cervical cancer screening use
|
Has been tested at least once
|
Has never been tested
|
Total
|
Has ever had sex
|
11 (8.94%)
|
112 (91.06%)
|
123 (100.00%)
|
Never had sex
|
4 (1.60%)
|
245 (98.94%)
|
249 (100.00%)
|
Total
|
15 (4.00%)
|
357 (96.00%)
|
372 (100.00%)
|
Chi-square Observed = 11.45
|
Critical Chi-Square = 3.48
|
P = 0.0007
|
Q of Yule = 0.71
|
OR = 6.02
|
|
OR-CI (95%) = [2.13; 17.03]
|
Review of the Health Belief Model
The key variables highlighted include the demographic variables, perceived severity of CC, perceived susceptibility to CC, perceived benefits of CCS, perceived barriers to CCS, the likelihood of CCS uptake, cues to action to utilize CCS, and self-efficacy, or confidence in one’s ability to take action.
This study indicated that high educational attainment (modifying factors) does not necessarily lead to increased uptake of CCS (Action). Most Nigerian women in this study believe that CC is a serious disease (perceived severity), that they can be exposed to (perceived susceptibility). However, they perceive the cost of CCS and the possibility of the procedure being stressful as part of their limitations (perceived barriers) to assessing CCS. On the other hand, most still believed that the benefit of CCS outweighs the stress of the procedure (perceived benefit), hence high intent to be screened (perceived self-efficacy). Nonetheless, some major factors (Cues to Action) would need to be put in place for an increased likelihood to go for CCS (Action). These factors include CCS being conducted by a female health worker, spousal consent, and CCS being provided during maternity visits, at religious centers, and at walk-in clinics within hostels (See Figure 1).