Understanding Female Patients’ Knowledge, Attitudes, and Practices Regarding Cervical Cancer Screening at Comboni Hospital
Kampala International University Uganda
ABSTRACT
Cervical cancer stands as the leading cause of cancer-related deaths among women in Uganda, with a prevalence rate of 48/100,000, one of the world’s highest. Tragically, over 80% of cases are diagnosed at an advanced stage, limiting treatment options. Early detection through screening among women aged 25 and above, followed by prompt treatment, can prevent most cases. This study aimed to assess knowledge, attitudes, and practices concerning cervical cancer screening among female patients at Comboni Hospital. Conducted as a cross-sectional descriptive study, it involved 350 women aged 20-49 seeking healthcare services at the hospital. Data collection employed a pretested questionnaire, and analysis utilized IBM SPSS version 25. The respondents, with a mean age of 31.73 years, were predominantly married (76.6%) and self-employed (42.9%), with 22.3% having completed tertiary education. While 92.3% were aware of cervical cancer, only 46% had contemplated undergoing screening, and merely 26.3% had been screened. Media served as the primary information source for 53.7% of participants, and half of those screened did so due to healthcare workers’ advice. Barriers to screening included high costs (27.7%), fear of positive results (14.6%), and apprehension about the screening process itself (14.3%). Despite a high level of awareness about cervical cancer, low screening uptake was attributed to the expense and unavailability of services. To improve access, the government should decentralize screening services to lower-tier health centers by training and equipping lower-level healthcare workers, particularly midwives. This strategy aims to overcome barriers and enhance screening accessibility for a larger population.
Keywords: knowledge, attitude, practice, cervical cancer.
INTRODUCTION
Every year, 7.6 million lives are lost to cancer worldwide more than AIDS, tuberculosis, and malaria combined [1]. A new report by the World Health Organization’s International Agency for Cancer Research (IARC) suggests that the incidence of cancer worldwide will grow by 75% by the year 2030, nearly doubling in some of the developing countries. Those increases will put a much larger burden on the poorly developed healthcare systems in such countries because care of cancer is much more expensive than care for infectious diseases [2].
The regions hardest hit by Cervical Cancer are among the world’s poorest. Central and South America, the Caribbean, Sub-Saharan Africa, parts of Oceania, and parts of Asia have the highest incidence rates of over 30 per 100,000 women [3].
Cervical Cancer is the second most common type of cancer among women, with virtually all cases linked to genital infection with the human papillomavirus (HPV). Among women in the urban setting, the development of Cervical Cancer is just bad luck and they do not want to know if they have it. Women who do not get screened often mention that they do not get tested because others will think they are having sex and if they are not sexually active, they do not need to be screened particularly among the Hispanic and Asian [4-8].
Cervical Cancer ranks as the 1st most frequent cancer among women in Uganda, and the 2nd most frequent cancer among women between 15 and 44 years of age [9-11]. It is estimated that every year approximately 40 women in every 100,000 develop Cervical Cancer in Uganda. Statistics also confirm that about half of the women with Cervical Cancer die within three years of diagnosis. Cervical Cancer is the most common malignancy among women in South western Uganda and the second most common in West Nile subregion [9]. However, the prevalence of cervical cancer in Bushenyi district is not well documented as there is no well-established population-based cancer registry.
The pathway to preventing deaths from Cervical Cancer is simple and effective. Precancerous changes in cervical tissue can loiter for years, but if they are identified and successfully treated early, the lesions will not develop into Cervical Cancer. Screening women for precancerous changes and treating the abnormal tissue seems to protect women from developing Cervical Cancer [12-18].
METHODOLOGY
Study design
A cross-sectional descriptive study design was used.
Study Area
The study was conducted in Comboni hospital in the OPD. Comboni Hospital is a PNFP Hospital, located in Ryabagoma Village Kyamuhunga Catholic Parish in Kyamuhunga Sub-County, Igara West Constituency Bushenyi District. It is a Roman Catholic Church based Institution in Mbarara Archdiocese affiliated to UCMB. It is approximately 80km from Mbarara town on Mbarara -Kasese High way and 15km from Bushenyi District headquarters. It has a bed capacity of 100 beds. It has departments of Maternity, Surgical, Medical, Operating Theatre and OPD.
Study population
The study population in this research included women aged 20-49 attending health care services at Comboni Hospital. VIA screening usage was suggested for women between 25-49 years of age (primary target). However, those under 25 years of age were only screened when considered to have an elevated risk of cervical abnormalities (these includes those who have had multiple partners, early sexual debut, are HIV positive or had previous abnormal screening results.
Inclusion criteria
All women of reproductive age (20-49) attending healthcare services at Comboni Hospital who were available during the data collection period and consented for the study.
Exclusion criteria
Females below 20 years, females aged 20-49 years who were mentally ill and the critically ill were excluded from the study.
Sample size determination
The sample size of female out patients was obtained by using Kish and Leslie formula (Chen & Rust, 2017).
Calculated as follows:
Where,
N = Calculated sample size,
P = Prevalence of cervical cancer screening. A previous study in Oyam district, Uganda by Waiswa et al., (2017) reported a prevalence of 35.1%.
so, P was taken to be 0.351.
Z = standard normal variation at 95% confidence (1.96)
= margin of error (5%)
Therefore,
N = = 350 women.
Sampling Procedures
The respondents were selected by Simple random sampling technique; here “the technique entails that every individual in the target population has an equal chance of being part of the sample”. The researcher approached as they present to OPD and any woman who meets the inclusion criteria and agrees to participate in the study were made to pick randomly a paper from the total 700 (350-Yes and 350-No) sample papers; if one picked “Yes” was enrolled until the required sample of 350 women was reached and if one picked “No” was not enrolled for the activity.
Data Analysis
The collected data was coded, entered in the computer and analyzed using IBM SPSS version 25. Descriptive statistics were used with confidence set at 95% to present the trends of the data. These included frequencies and percentages which were presented in table and figure forms where appropriate.
Ethical consideration
Prior to data collection, ethical clearance was sought from the faculty of clinical medicine and dentistry and from Institutional Review committee (IRC) of KIU-WC. Informed consent sought from all respondents before executing the study. Respondents were informed that their participation was voluntary and all information was kept confidential.
RESULTS
This section presents the results on the background distinctiveness of the 350 respondents. These comprise age of the respondents, education level, and marital status. The results on the background characteristics are as presented in table 1 below.
The mean age of respondents was 31.73 years ±5.94 (std. deviation). Majority of the participants (76.6%, n=268) were married and almost a half of the participants (42.9%, n=150) were self-employed. A small number of the participants (22.3%, n=78) had completed tertiary level of education. Table 1.
Table 1: Socio-demographic characteristics of respondents
| Characteristics | Frequency (N=350) | Percent |
| Age (years) | ||
| 20-29 | 154 | 44.0 |
| 30-39 | 152 | 43.4 |
| 40-49 | 44 | 12.6 |
| Education level | ||
| No formal education | 55 | 15.7 |
| Primary education | 142 | 40.6 |
| Secondary education | 75 | 21.4 |
| Tertiary Education | 78 | 22.3 |
| Occupation | ||
| Employed | 65 | 18.6 |
| Unemployed | 67 | 19.1 |
| Self employed | 150 | 42.9 |
| House wife | 68 | 19.4 |
| Marital status | ||
| Single | 29 | 8.3 |
| Married | 268 | 76.6 |
| Divorced | 8 | 2.3 |
| Separated | 12 | 3.4 |
| Widowed | 33 | 9.4 |
Results from the study show that majority of the participants (92.3%, n=323) had heard about cancer of the cervix compared to only few (7.7%, n=27) who had never heard about cervical cancer. Figure 2.
Figure 1: Knowledge about cervical cancer
The study showed that the most common source of information among participants was either television or radio (53.7%, n=188) followed by health workers at the health facility (32.0%, n=112). Friends contributed 5.4% (n=19) of the source of information while the least number got the information about cervical cancer from brochures or posters (1.1%, n=04). Figure 3.
Figure 2: Sources of information about cervical cancer
The respondents were also asked about the signs and symptoms of cancer of the cervix. The findings revealed that, majority of the respondents did not know the symptoms as reported by 44.9% (n=157) of the respondents. The cervical cancer according to 23.4% (n=82) of the respondents is characterized by vaginal bleeding between periods. Other signs that were reported were persistent vaginal discharge (12.6%, n=44), discomfort or pain during sex (9.7%, n=34) and persistent lower back pain 5.1% (n=18). A least number (0.9%, n=3) mentioned unusual prolonged periods. Table 2
Table 2: Knowledge on signs and symptoms of Ca cervix
| Sign/symptom | Frequency | Percent |
| vaginal bleeding between periods | 82 | 23.4 |
| Post-menopausal vaginal bleeding | 12 | 3.4 |
| Persistent vaginal discharge | 44 | 12.6 |
| Unusual prolonged/heavy periods | 3 | 0.9 |
| Pain during sex | 34 | 9.7 |
| Persistent lower back pain | 18 | 5.1 |
| Don’t know | 157 | 44.9 |
| Total | 350 | 100.0 |
Figure 5 below illustrates that majority of the participants (82%, n=286) were aware of the availability of Ca cervix screening tests compared to 18% (n=64) who did not know about Ca of cervix screening test.
Figure 4: Women’s Knowledge on Cervical Cancer Screening
Findings in table 3 show that, women groups are the most preferred places to reach women with cervical cancer screening messages/information. This was reported by majority (43.1%, n=151) of the participants followed by 23.7% (n=83) who reported that health facilities were the best places and 14.6% (n=51) who reported places of worship as the best source. The least number (3.4%, n=12) reported market places as the best places to find women and give them cancer screening information messages.
Table 3: Best place to reach out to women
| Best place to reach women | Frequency | Percent |
| In women’s group | 151 | 43.1 |
| Places of worship | 51 | 14.6 |
| Health facility | 83 | 23.7 |
| At their homes | 24 | 6.9 |
| Market places | 12 | 3.4 |
| Television/Radio | 29 | 8.3 |
Figure 6 below demonstrates that more than half of the participants (54%, n=190) were not willing to go for cervical cancer screening indicating a negative attitude among majority of the participants. However, 46% (n=160) were willing to go for cervical cancer screening. Figure 6.
Figure 5: Attitude towards cervical cancer screening among female patients
The study findings show that majority of the participants (73.7%, n=258) had never been screened for cervical cancer as compared to only 26.3% (n=92) who had ever been screened for cervical cancer. Figure 7.
Figure 6: Cervical cancer screening practices
Participants who had ever been screened for cervical cancer were asked the last time they did and results are summarized in figure 8 below. Majority (43.5%, n=40) were last screened 3 to 5 years ago while 27.2% (n=25) were last screened 1 to 2 years ago. A small number, 8.7% (n=8) were last screened more than five years ago. Figure 8.
Figure 7: Last time screened for cervical cancer
The study shows that among respondents who had been screened, half (50.0%, n=46) did so because the health workers suggested to them. Other reasons included free service (15.2%, n=14), awareness that if detected early it can be treated (19.6%, n=18) and lastly, 5.4% (n=5) were encouraged by their friends. Table 4
Table 4: Reasons for going for screening
| What made you go for screening | Frequency | Percent |
| Friends/family encouraged me | 5 | 5.4 |
| Health worker suggested | 46 | 50.0 |
| The service was free | 14 | 15.2 |
| Had symptoms that made me want to screen | 9 | 9.8 |
| Aware that if found early it is treatable | 18 | 19.6 |
DISCUSSION
The current study found that the knowledge on the cervical cancer among the participants was high at 92.3%. The knowledge level in this study is higher than that of a study in Oyam district, Northern Uganda which reported that 62.7% of the total participants knew about cervical cancer and screening test [19]. Low knowledge about cervical cancer was also reported by studies in Nigeria [20 and Ethiopia [21]. The difference in findings between the present study and afore mentioned studies could be attributed to differences in health promotion implementation programs.
Concerning the knowledge on signs and symptoms of cervical cancer, majority of the participants did not know any of the signs and symptoms. These results reveal that even though majority of women were aware of the cervical cancer, their knowledge about cervical cancer signs and symptoms was scanty. Similar findings were recorded in a study in Ilorin, Nigeria by Aboyeji and colleagues who found that 81.7% of the patients with high grade cancer of cervix were not aware of the signs and symptoms and held the belief that their problem was just menstrual recurrence, lower abdominal pain and menses that were irregular [22].
Cancer of the cervix is associated with Human papilloma virus (HPV) which can be transmitted sexually. The well-known risk factors to HPV infection include the number of sexual partners, the sexual partner’s number of previous sexual partners, immune system status and partner’s circumcision status [23]. From the findings above, the majority seem to be knowledgeable of multiple partners as a risk factor, however, it is also evident that there are participants with inadequate knowledge of the risk factors of cancer of the cervix hence need for strengthened education by health providers and programs to make a deliberate effort to educate the public on the risk factors associated with cervical cancer.
This study also reported that 82% of women who participated were knowledgeable on cervical cancer screening test available in the health facilities. This finding concurs with that of Bouslah and others in their study among Tunisian women where it was reported that majority (98.1%) were aware of the availability of screening test in the hospitals. However, it has been reported by other studies in Africa that there is generally lack of programs for screening for early recognition of cancer in most states in Sub Sahara Africa [21] especially the lower health facilities which are near the communities. Moreover, most screening programs are undertaken as pilots and close when the project period is over [20]. It is well known that most abnormal changes and early cancers are found in women who have regular screening; most advanced cancers of the cervix are found in women who have not had routine screening which underscores the need for awareness regarding regular screening all the more important.
With regard to attitude, majority (54%) of the women were found to be unwilling to regularly consult a health care provider for screening of cervical cancer while only 46% were willing to regularly go for screening. 76.0% of the women also felt that all women of child bearing age should be screened for cervical cancer. However, others suggested that only women with symptoms suggestive of cancerous cervix should be screened as well that only women with promiscuous life cycle need to be screened. These findings are contrary to those of a study in rural India which that majority (84.6% of the participants had a positive attitude [24]. The difference in attitude levels could have been influenced by socioeconomic differences between participants. Attitude is essential in utilization of health care services like cervical cancer screening. In an Iranian study, good attitude was strongly linked with increase in chances of undertaking screening services and was associated with five times increase in screening for those with good attitude [25].
CONCLUSION
This study concludes that the level of women’s knowledge on cervical cancer as well as screening services on cervical cancer is good.
The attitude towards cervical cancer screening, was found to be poor as more than half of the participants have never considered going for screening.
This study also found the practices on cervical cancer screening by female patients is low as most female do not want to go for screening.
- Cervical cancer. 2018; WHO. https://www.who.int/cancer/prevention/diagnosis-screening/cervical-cancer/en/
- Prevention and control of cervical cancer. 2019; WHO. https://www.who.int/reproductivehealth/topics/cancers/en/
- Bychkovsky, B. L., Ferreyra, M. E., Strasser-Weipp, K., Herold, C., De Lima, L. G., Dizon, D. S., Schmeler, K. M., Del Carmen, M., Randall, T. C., Nogueira-Rodrigues, A., Calabrich, A. F., St. Louis, J., Vail, C. M., & Goss, P. E. (2016). Cervical cancer control in Latin America: A call to action. In Cancer. https://doi.org/10.1002/cncr.29813
- Tsikouras, P., Zervoudis, S., Manav, B., Tomara, E., Iatrakis, G., Romanidis, C., Bothou, A., & Galazios, G. (2017). Cervical cancer: Screening, diagnosis and staging. In Journal of B.U.ON.
- Obeagu, E. I., & Obeagu, G. U. (2023). An update on premalignant cervical lesions and cervical cancer screening services among HIV positive women. J Pub Health Nutri., 6 (2):141-154.links/63e538ed64252375639dd0df/An-update-on-premalignant-cervical-lesions-and-cervical-cancer-screening-services-among-HIV-positive-women.pdf.
- Akandinda, M., Obeagu, E. I., Madekwe, C. C., & Nakyeyune, S. (2022). A Review on Factors Associated with HPV Vaccination in Africa. Madonna University journal of Medicine and Health Sciences, 2(3):1-5. https://madonnauniversity.edu.ng/journals/index.php/medicine/article/view/68.
- Obeagu, E. I., Byukusenge, C., & Obeagu, G. U. (2023). Cervical Cancer: A Review on Young Women. Eurasian Experiment Journal of Biological Sciences (EEJBS), 4(1):92-96
- Okoroiwu, I. L., Obeagu, E. I., & Vivian, E. V. (2021). Assessment of White Blood Cell Count and Platelet Count in Women on Hormonal Contraceptives in Owerri, Imo State, Nigeria. J Res Med Dent Sci., 9(12):498-501. links/61b1eb474d7ff64f0537353d/Assessment-of-White-Blood-Cell-Count-and-Platelet-Count-in-Women-on-Hormonal-Contraceptives-in-Owerri-Imo-State-Nigeria.pdf.
- Nakisige, C., Schwartz, M., & Ndira, A. O. (2017). Cervical cancer screening and treatment in Uganda. Gynecologic Oncology Reports, 2017; 20, 37–40. https://doi.org/10.1016/j.gore.2017.01.009
- Nwosu, D. C., Obeagu, E. I., Nwanjo, H. U., Ogomaka, A. I., Kanu, S., & Nnorom, R. M. (2015). Female Genital Schistosomiasis (FGS) in S. Haematobiumin Infection: A review. European Journal of Biomedical and Pharmaceutical Sciences, 2 (1): 434-438
- Obeagu, E. I., Babar, Q., Vincent, C. C., Anyanwu, C. O., & Uduchi, I. O. (2021). Advances in Therapeutic Strategies of Immunotherapy in Cancer Treatment. World Journal of Pharmacy and Pharmaceutical Sciences, 10(8):2144-64. links/610b814d0c2bfa282a2381eb/ADVANCES-IN-THERAPEUTIC-STRATEGIES-OF-IMMUNOTHERAPY-IN-CANCER-TREATMENT.pdf.
- Geremew, A. B., Gelagay, A. A., & Azale, T. (2018). Comprehensive knowledge on cervical cancer, attitude towards its screening and associated factors among women aged 30-49 years in Finote Selam town, northwest Ethiopia. Reproductive Health, https://doi.org/10.1186/s12978-018-0471-1
- Obeagu, E. I., Shafie, A. O., Bunu, U. O., & Obeagu, G. U. (2023). Lung cancer and smoking relationship. J. Curr. Res. Biol. Med., 8(1): 28-33
- Obeagu, E. I., Byukusenge, C., & Obeagu, G. U. (2023). Cervical Cancer: A Review on Young Women. Eurasian Experiment Journal of Biological Sciences, 4(1).
- Okorie, N., Obeagu, E. I., Odigbo, C. N., Ibe, O. E., Usanga, V. U., Jacob, I. C., Obi, I. (2022). Cytological Evaluation of Urinary Samples among Vesicovaginal Fistula Patients in National Obstetrics Fistula Centre, Southeastern Nigeria. Asian Journal of Medicine and Health, 20(10):136-46.
- Umoke, C. I., Umoke, C. C., Orieji, P., Madukwe, J., Bunu, U. O., & Obeagu, E. I. (2023). The demonstration of expressed microsatelite protein (MLH1) on colorectal carcinoma tissue. Int. J. Adv. Res. Biol. Sci., 10(3):144-50.
- Obeagu, E. I., & Obeagu, G. U. (2023). A Review of knowledge, attitudes and socio-demographic factors associated with non-adherence to antiretroviral therapy among people living with HIV/AIDS. Int. J. Adv. Res. Biol. Sci., 10(9):135-42.DOI:22192/ijarbs.2023.10.09.015
- Obeagu, E. I., Scott, G. Y., Amekpor, F., & Obeagu, G. U. (2023). Implications of CD4/CD8 ratios in Human Immunodeficiency Virus infections. Int. J. Curr. Res. Med. Sci., 9(2):6-13.
- Waiswa, A., Nsubuga, R., Muwasi, M., Kimera, I., Ndikabona, G., Tusingwire, P. D., Mshilla, M., Ovuga, E., & Akera, P. (2017). Knowledge and Attitude towards Cervical Cancer Screening among Females Attending out Patient Department in Health Centre IIIs in Oyam District. Open Journal of Preventive Medicine. https://doi.org/10.4236/ojpm.2017.74005
- Awodele, O., Adeyomoye, A. A., Awodele, D. F., Kwashi, V., Awodele, I. O., & Dolapo, D. C. (2014). A study on cervical cancer screening amongst nurses in lagos university teaching hospital, lagos, nigeria. Journal of Cancer Education. https://doi.org/10.1007/s13187-010-0187-6
- Raychaudhuri, S., & Mandal, S. (2015). Current status of knowledge, attitude and practice (KAP) and screening for cervical cancer in countries at different levels of development. In Asian Pacific Journal of Cancer Prevention. https://doi.org/10.7314/APJCP.2012.13.9.4221
- Aboyeji, P. A., Ijaiya, M. D. A., & Jimoh, A. G. A. (2015). Knowledge, Attitude and Practice of Cervical Smear as a Screening Procedure for Cervical Cancer in Ilorin, Nigeria. Tropical Journal of Obstetrics and Gynaecology, https://doi.org/10.4314/tjog.v21i2.14482
- 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. https://doi.org/10.1186/s12905-017-0365-3
- Basu, P., Hassan, S., Fileeshia, F., Mohamed, S., Nahoodha, A., Shiuna, A., Sulaiman, A., Najeeb, N., & Saleem, F. J. (2014). Knowledge, attitude and practices of women in Maldives related to the risk factors, prevention and early detection of cervical cancer. Asian Pacific Journal of Cancer Prevention, https://doi.org/10.7314/APJCP.2014.15.16.6691
- Keshavarz, Z., Simbar, M., & Ramezankhani, A. (2014). Factors for performing breast and cervix cancer screening by Iranian female workers: A qualitative-model study. Asian Pacific Journal of Cancer Prevention, 12, 1517–1522.
CITE AS: Rwahwire David Julius (2023). Understanding Female Patients’ Knowledge, Attitudes, and Practices Regarding Cervical Cancer Screening at Comboni Hospital. INOSR Experimental Sciences 12(2):194-204. https://doi.org/10.59298/INOSRES/2023/2.15.1000