Background
Cervical cancer remains a major cause of morbidity and mortality among women in resource constrained settings due to low access to cancer screening and vaccination [
1,
2]. Indeed, coverage of cancer screening services is lowest in low and middle income countries [
3]. These countries have only a few trained and skilled health workers to carry out screening, and lack healthcare resources to sustain such programmes [
4]. Consequently, women with cervical cancer are not identified until they are at an advanced stage of disease, resulting in high morbidity and mortality [
4]. On the other hand, many developing countries are still in the initial stages of rolling out cervical cancer vaccination among their populations. For example, in Uganda, cervical cancer vaccinations among girls aged between 9 to 13 years in schools and the community were piloted in 2008 and a national strategic plan launched in 2010 [
5,
6]. Other sub-Saharan African countries such as Ghana and Kenya have also rolled out cervical cancer vaccinations among their population [
7,
8].
Cervical cancer is potentially preventable, and effective screening programmes can lead to a significant reduction in the morbidity and mortality associated with this cancer [
2,
9] especially if detected in early stages [
10]. The World Health Organization (WHO) recommends screening and vaccination programmes globally [
11]. However, only a small percentage (5–27%) of women in sub-Saharan Africa report having received cervical cancer screening [
12‐
19]. This is even lower in the East African region where the prevalence of human papilloma virus (HPV) (20%) is high, and the incidence rates of cervical cancer are highest [
20]. Understanding factors that influence intention to screen for cervical cancer among women is important to inform programmes aimed at increasing utilisation of screening services in sub-Saharan Africa. Previous studies show that women’s intention to screen, and attendance of cervical cancer screening is influenced by: demographic factors such as occupation, living with a partner; attitudinal factors such as perception of risk and disease; social factors for example discussions by health workers; and health system factors such as distance to health facilities and awareness of the service [
18,
19].
HPV, which is mainly sexually transmitted, causes most of the cervical cancer cases [
21]. Highly effective prophylactic vaccines against HPV −16 and HPV −18 have been shown to prevent over 70% of these cases worldwide [
22]. HPV vaccinations can therefore significantly reduce the incidence of cervical cancer among women. Moreover, WHO recommends offering HPV vaccine to girls between 9 and 13 years, prior to sexual debut, as the vaccine is most efficacious if girls have not already been exposed to the virus [
23]. The success of the vaccine would depend on levels of acceptability and uptake, which heavily relies on parent’s willingness to have their eligible daughters vaccinated [
24]. Prior research among parents has reported predictors of vaccinations of girls to include perception of the severity of the disease, belief of daughter being at risk, higher education and income, attitudes towards vaccines, previous awareness of the vaccine, and recommendations by vaccine providers [
7,
25‐
28]. Barriers to cervical cancer vaccination such as concerns about vaccine safety, danger to daughter, sexual behaviours, and lack of provider recommendation have also been highlighted [
7,
25‐
29]. However, there has been a paucity of such studies in Uganda to provide context specific barriers and inform on-going vaccine promotion campaigns. This study assessed the factors associated with intention to screen for cervical cancer among women in eastern Uganda, and willingness to have their daughters vaccinated against the disease.
Results
Socio-demographic characteristics of respondents
All the 900 respondents selected took part in the study. Majority of these were from rural areas 610 (67.8%) and married 767 (85.2%). Only a quarter 228 (25.3%) of respondents had attained post primary education (Table
1).
Table 1
Socio-demographic characteristics of respondents (N = 900)
District | Bugiri | 452 (50.2) |
| Mayuge | 448 (49.8) |
Residence | Rural | 610 (67.8) |
| Semi-urban/urban | 290 (32.2) |
Age (years) | Mean (SD) | 32.9 (±6.7) |
| 25–39 | 703 (78.1) |
| 40–49 | 197 (21.9) |
Education level | None/primary | 672 (74.7) |
| Post primary | 228 (25.3) |
Religion | Muslims | 382 (42.4) |
| Christians | 518 (57.6) |
Marital status | Single | 133 (14.8) |
| Married | 767 (85.2) |
Occupation | Farming | 502 (55.8) |
| Others (business, housewife, civil servant) | 195 (21.7) |
Parity | Mean (SD) | 5.04 (±2.7) |
| Four and below | 430 (47.8) |
| Above four | 470 (52.2) |
Household monthly income | Less than $40 | 622 (69.1) |
| $40 and above | 278 (30.9) |
Household head | No | 757 (84.1) |
| Yes | 143 (15.9) |
Ever tested for HIV | No | 144 (16.0) |
| Yes | 756 (84.0) |
Ever used modern family planning method | No | 317 (35.2) |
| Yes | 583 (64.8) |
Cervical cancer screening status | Not screened | 857 (95.2) |
| Screened | 43 (4.8) |
Intention to screen for cervical cancer
Majority 819 (91.0%) of respondents stated that they intended to go for cervical cancer screening in the following six months. Only 57 (6.3%) did not intend to undergo the procedure while 24 (2.7%) were undecided. Reasons for intention to screen were: 603 (73.6%) to know status, 256 (31.3%) thought it was important, 202 (24.7%) wanted to reduce their chances of getting the disease, and 20 (2.4%) had been told to do so by a health worker. Among those who did not intend to screen, 28 (49.1%) stated that it was not necessary or important, 9 (15.8%) cited health facility being far away, 6 (10.5%) high costs involved, 5 (8.8%) said they had been screened recently, and 13 (22.8%) gave other reasons (fear of pain, lack of signs and symptoms, and already undergoing treatment). Among respondents who had never screened for cervical cancer, intention to screen was at 91.6% (785/857). When respondents were asked whether they would be willing to undergo screening if the service was offered at an affordable cost to them, majority 828 (92.0%) said they would. Moreover, 863 (95.9%) stated willingness to screen if the service was provided free of charge.
Respondents’ willingness for vaccination of themselves and their daughters
Of the study respondents, more than nine in ten 815 (90.5%) reported willingness to be vaccinated against cervical cancer if it were recommended. The rest reported unwillingness 61 (6.8%) or uncertainty 24 (2.7%). Majority 813 (90.4%) also reported that they would allow their daughters to be vaccinated against cervical cancer, 59 (6.6%) wouldn’t and the rest 28 (3.1%) were undecided.
Socio-demographic characteristics associated with intention to screen, and willingness to vaccinate daughters against cervical cancer
Respondents from Mayuge district (unadjusted PR = 1.10, 95% CI = 1.06–1.14) and those whose households earned 40 US dollars or more per month (unadjusted PR = 1.07, 95% CI = 1.04–1.11) had a 10% and 7% higher intention to screen for cervical cancer respectively compared with their counterparts. On the other hand, respondents who had accessed cervical cancer screening were less likely to intend to undergo another test in the subsequent six months (unadjusted PR = 0.86, 95% CI = 0.74–0.99). The respondents’ district of residence (unadjusted PR = 1.05, 95% CI = 1.01–1.09), residence in a rural or urban area (unadjusted PR = 1.05, 95% CI = 1.01–1.08), occupation (unadjusted PR = 0.94, 95% CI = 0.91–0.98), and household income (unadjusted PR = 1.05, 95% CI = 1.01–1.08) were all significantly associated with willingness to vaccinate their daughters against cervical cancer (Table
2).
Table 2
Knowledge factors with intention to screen and willingness to vaccinate daughters against cervical cancer
Characteristic | N (%) | Unadjusted PR (95% CI) |
p-value | N (%) | Unadjusted PR (95% CI) |
p-value |
Early detection of cervical cancer is helpful |
No | 36 (80.0) | | | 39 (86.7) | | |
Yes | 783 (94.2) | 1.18 [1.02–1.36] |
0.029* | 774 (93.6) | 1.08 [0.96–1.21] | 0.194 |
Cervical cancer can be prevented |
No | 246 (92.8) | | | 246 (92.1) | | |
Yes | 573 (93.8) | 1.01 [0.97–1.05] | 0.611 | 567 (93.7) | 1.02 [0.98–1.06] | 0.412 |
Knew recommended age for start of cervical cancer screening |
No | 785 (93.6) | | | 782 (93.5) | | |
Yes | 34 (91.9) | 0.98 [0.89–1.08] | 0.717 | 31 (86.1) | 0.92 [0.81–1.05] | 0.221 |
Knew that one can be vaccinated against cervical cancer |
No | 282 (90.7) | | | 280 (90.0) | | |
Yes | 537 (95.0) | 1.05 [1.01–1.09] |
0.022* | 533 (95.0) | 1.05 [1.01–1.10] |
0.011* |
Knew more than one preventive measure for cervical cancer |
No | 570 (93.4) | | | 580 (94.5) | | |
Yes | 249 (93.6) | 1.00 [0.96–1.04] | 0.927 | 233 (90.3) | 0.96 [0.91–0.99] |
0.047* |
Knew more than one symptom of cervical cancer |
No | 382 (95.0) | | | 387 (96.3) | | |
Yes | 437 (92.2) | 0.97 [0.94–1.00] | 0.085 | 426 (90.6) | 0.94 [0.01–0.97] |
0.001* |
Knew at least one test for cervical cancer |
No | 455 (95.8) | | | 448 (94.9) | | |
Yes | 364 (90.8) | 0.95 [0.91–0.98] |
0.004* | 365 (91.2) | 0.96 [0.93–0.99] |
0.036* |
Knew someone who had ever been screened for cervical cancer |
No | 538 (93.6) | | | 546 (94.5) | | |
Yes | 281 (93.4) | 0.99 [0.96–1.03] | 0.905 | 267 (90.8) | 0.96 [0.92–1.00] | 0.062 |
Knew someone who had ever been diagnosed with cervical cancer |
No | 569 (93.3) | | | 576 (93.9) | | |
Yes | 250 (93.9) | 1.00 [0.97–1.04] | 0.691 | 237 (91.5) | 0.97 [0.93–1.01] | 0.218 |
Knew someone who had died from cervical cancer |
No | 568 (93.3) | | | 572 (93.6) | | |
Yes | 251 (94.0) | 1.00 [0.97–1.04] | 0.676 | 241 (92.3) | 0.99 [0.95–1.03] | 0.507 |
Knowledge factors associated with intention to screen, and willingness to vaccinate daughters against cervical cancer
Reporting that early detection of cervical cancer is helpful (unadjusted PR = 1.18, 95% CI = 1.02–1.36), knowing that one could be vaccinated against cervical cancer (unadjusted PR = 1.05, 95% CI = 1.01–1.09), and knowledge of at least one test for cervical cancer (unadjusted PR = 0.95, 95% CI = 0.91–0.98) were significantly associated with intention to screen for cervical cancer at bivariate analysis. On the other hand, knowing that one could be vaccinated against cervical cancer (unadjusted PR = 1.05, 95% CI = 1.01–1.10), knowing more than one preventive measure (unadjusted PR = 0.96, 95% CI = 0.91–0.99) or symptom of cervical cancer (unadjusted PR = 0.94, 95% CI = 0.01–0.97), and knowledge of at least one test for cervical cancer (unadjusted PR = 0.96, 95% CI = 0.93–0.99) were significantly associated with willingness to vaccinate daughters against cervical cancer (Table
3).
Table 3
Attitudes with intention to screen and willingness to vaccinate daughters against cervical cancer
| N (%) | Unadjusted PR (95% CI) |
p-value | N (%) | Unadjusted PR (95% CI) |
p-value |
Cervical cancer is a severe disease |
No | 19 (45.2) | | | 7 (17.1) | | |
Yes | 796 (96.1) | 2.12 [1.52–2.96] |
<0.001* | 800 (96.9) | 5.68 [2.89–11.12] |
<0.001* |
I am at risk of getting cervical cancer |
No | 62 (73.8) | | | 47 (56.6) | | |
Yes | 642 (95.8) | 1.29 [1.14–1.48] |
<0.001* | 647 (97.3) | 1.72 [1.42–2.07] |
<0.001* |
Cervical cancer screening is important |
No | 20 (52.6) | | | 7 (18.4) | | |
Yes | 788 (95.4) | 1.81 [1.34–2.45] |
<0.001* | 802 (97.3) | 5.28 [2.70–10.32] |
<0.001* |
Only women who are sexually active need cervical cancer screening |
Yes | 373 (95.9) | | | 378 (96.9) | | |
No | 358 (90.9) | 0.95 [0.91–0.98] | 0.005 | 351 (89.5) | 0.92 [0.89–0.96] |
<0.001* |
Women who have had sexually transmitted infections are more likely to get cervical cancer |
No | 169 (86.2) | | | 152 (79.2) | | |
Yes | 578 (96.0) | 1.11 [1.05–1.18] |
<0.001* | 588 (97.7) | 1.23 [1.15–1.33] |
<0.001* |
Chances of curing cervical cancer are better when the disease is discovered at an early stage |
No | 97 (78.9) | | | 89 (70.6) | | |
Yes | 666 (96.2) | 1.22 [1.11–1.34] |
<0.001* | 671 (97.7) | 1.38 [1.23–1.55] |
<0.001* |
Cervical cancer is not a death sentence for most people |
No | 320 (95.0) | | | 319 (94.9) | | |
Yes | 407 (92.5) | 0.97 [0.94–1.01] | 0.157 | 401 (91.3) | 0.96 [0.93–0.99] |
0.046* |
There is much a woman can do to reduce her chances of getting cervical cancer |
No | 415 (95.6) | | | 410 (95.1) | | |
Yes | 272 (90.7) | 0.95 [0.91–0.99] |
0.012* | 269 (89.1) | 0.94 [0.89–0.98] |
0.004* |
Women who have cervical cancer will have some symptoms showing it |
Yes | 700 (96.1) | | | 706 (97.4) | | |
No | 53 (68.8) | 0.71 [0.61–0.83] |
<0.001* | 41 (54.7) | 0.56 [0.46–0.69] |
<0.001* |
Cervical cancer runs in families |
No | 371 (92.7) | | | 361 (91.2) | | |
Yes | 302 (94.4) | 1.02 [0.98–1.05] | 0.374 | 307 (95.0) | 1.04 [1.00–1.08] |
0.039* |
Women only need cervical cancer screening tests during child bearing years |
Yes | 412 (95.8) | | | 412 (96.5) | | |
No | 321 (89.7) | 0.93 [0.89–0.97] |
0.001* | 318 (89.1) | 0.92 [0.89–0.96] |
<0.001* |
Their family would approve of children being vaccinated against cervical cancer |
No | 34 (56.7) | | | 9 (15.5) | | |
Yes | 752 (96.5) | 1.70 [1.36–2.13] |
<0.001* | 778 (98.9) | 6.38 [3.49–11.63] |
<0.001* |
Attitude factors associated with intention to screen and willingness to vaccinate daughters against cervical cancer
Majority 796 (96.1%) of respondents thought that cervical cancer was a severe disease and these had a significantly higher intention to screen (unadjusted PR = 2.12, 95% CI = 1.52–2.96). Other attitudinal factors associated with intention to screen for cervical cancer were: belief of being at risk of getting cervical cancer (unadjusted PR = 1.29, 95% CI = 1.14–1.48), stating that cervical cancer screening is important (unadjusted PR = 1.81, 95% CI = 1.34–2.45), and that chances of curing cervical cancer are better when it is discovered at an early stage (unadjusted PR = 1.22, 95% CI = 1.11–1.34), and that their family would approve of children being vaccinated against cervical cancer (unadjusted PR = 1.70, 95% CI = 1.36–2.13). Similarly, respondents who stated that cervical cancer is a severe disease (unadjusted PR = 5.68, 95% CI = 2.89–11.12), believed were at risk of getting cervical cancer (unadjusted PR = 1.72,, 95% CI = 1.42–2.07), stated that; cervical cancer screening is important (unadjusted PR = 5.28, 95% CI = 2.70–10.32), the chances of curing cervical cancer are better when the disease is discovered at an early stage (unadjusted PR = 1.38, 95% CI = 1.23–1.55), and that their family would approve of children being vaccinated against cervical cancer (unadjusted PR = 6.38, 95% CI = 3.49–11.63) had a significantly higher willingness to vaccinate their daughters against the disease (Table
4).
Table 4
Health facility factors with intention to screen and willingness to vaccinate daughters against cervical cancer
Characteristic | N (%) | Unadjusted PR (95% CI) |
p-value | N (%) | Unadjusted PR (95% CI) |
p-value |
Where health care is accessed when sick |
Private facility | 166 (97.1) | | | 168 (96.5) | | |
Government facility | 653 (92.6) | 0.95 [0.92–0.99] |
0.006* | 645 (92.4) | 0.96 [0.92–0.99] |
0.015* |
Where reproductive health care is accessed |
Private facility | 153 (96.8) | | | 157 (97.5) | | |
Government facility | 666 (92.8) | 0.96 [0.92–0.99] |
0.016* | 656 (92.3) | 0.95 [0.91–0.98] |
0.001* |
Ease of access of reproductive health care |
Very/somewhat difficult | 372 (92.8) | | | 378 (94.9) | | |
Not difficult | 447 (94.1) | 1.01 [0.98–1.05] | 0.428 | 435 (91.8) | 0.97 [0.93–1.00] | 0.056 |
Have challenges in accessing reproductive health care |
Yes | 480 (92.5) | | | 487 (94.0) | | |
No | 339 (95.0) | 1.02 [0.99–1.06] | 0.131 | 326 (92.1) | 0.98 [0.94–1.02] | 0.279 |
Ever been recommended for screening by health worker |
No | 749 (94.0) | | | 737 (92.9) | | |
Yes | 70 (88.6) | 0.94 [0.87–1.02] | 0.155 | 76 (96.2) | 1.03 [0.99–1.08] | 0.157 |
Knew where cervical cancer screening is provided |
No | 496 (95.7) | | | 489 (95.9) | | |
Yes | 323 (90.2) | 0.94 [0.91–0.98] |
0.003* | 324 (89.5) | 0.93 [0.89–0.97] |
0.001* |
Distance to health facility where screening is done (n–372) |
5 or more km | 140 (84.8) | | | 139 (84.2) | | |
Less than 5 km | 183 (94.8) | 1.12 [1.04–1.20] |
0.003* | 187 (94.9) | 1.13 [1.05–1.21] |
0.001* |
Distance to nearest health facility |
5 or more km | 128 (91.4) | | | 125 (89.9) | | |
Less than 5 km | 691 (93.9) | 1.03 [0.97–1.08] | 0.336 | 688 (93.9) | 1.04 [0.98–1.10] | 0.153 |
Health facility factors associated with intention to screen and willingness to vaccinate against cervical cancer
Respondents who accessed health care (unadjusted PR = 0.95, 95% CI = 0.92-0.99) and reproductive health care (unadjusted PR = 0.96, 95% CI = 0.92–0.99) from a government health facility, and those who knew where cervical cancer screening was provided (unadjusted PR = 0.94, 95% CI = 0.91–0.98) had a lower intention to screen for cervical cancer compared with their counterparts. On the other hand, respondents who lived within 5 kilometres from the health facility where screening services were provided had a higher intention to screen for cervical cancer (unadjusted PR = 1.12, 95% CI = 1.04–1.20). Similarly, respondents who lived within 5 kilometres from the health facility had a higher willingness for vaccination of their daughters (unadjusted PR = 1.13, 95% CI = 1.05–1.21). In contrast, there was less willingness for respondents who accessed health care (unadjusted PR = 0.96 95% CI = 0.92–0.99) and reproductive health care (unadjusted PR = 0.95, 95% CI = 0.91-0.98) from a government health facility, those who found it easy to access reproductive health care (unadjusted PR = 0.97, 95% CI = 0.93–1.00), and those who knew where cervical cancer screening was provided (unadjusted PR = 0.93, 95% CI = 0.89–0.97) (Table
5).
Table 5
Socio-demographic characteristics with intention to screen, and willingness to vaccinate daughters against cervical cancer
District |
Bugiri | 388 (89.0) | | | 404 (90.9) | | |
Mayuge | 431 (97.9) | 1.10 [1.06–1.14] |
<0.001* | 409 (95.6) | 1.05 [1.01–1.09] |
0.007* |
Residence |
Rural | 551 (92.6) | | | 542 (91.9) | | |
Semi-urban/urban | 268 (95.4) | 1.03 [0.99–1.06] | 0.093 | 271 (96.1) | 1.05 [1.01–1.08] |
0.009* |
Age (years) |
25–39 | 643 (93.7) | | | 638 (93.5) | | |
40–49 | 176 (92.6) | 0.99 [0.94–1.03] | 0.603 | 175 (92.1) | 0.98 [0.94–1.03] | 0.508 |
Education level |
None/primary | 617 (94.0) | | | 610 (93.7) | | |
Post primary | 202 (91.8) | 0.98 [0.93–1.02] | 0.283 | 203 (91.9) | 0.98 [0.94–1.02] | 0.376 |
Religion |
Muslims | 353 (94.9) | | | 350 (94.6) | | |
Christians | 466 (92.5) | 0.97 [0.94–1.00] | 0.138 | 463 (92.2) | 0.97 [0.94–1.01] | 0.159 |
Marital status |
Single | 118 (92.9) | | | 120 (93.7) | | |
Married | 701 (93.6) | 1.01 [0.96–1.06] | 0.782 | 693 (93.1) | 0.99 [0.95–1.04] | 0.795 |
Occupation |
Farming | 458 (94.2) | | | 470 (95.5) | | |
Other (business, housewife, civil servant) | 361 (92.6) | 0.98 [0.95–1.02] | 0.325 | 343 (90.3) | 0.94 [0.91–0.98] |
0.004* |
Parity |
Above four | 426 (92.4) | | | 429 (93.5) | | |
Four and below | 393 (94.7) | 1.02 [0.99–1.06] | 0.167 | 384 (92.9) | 0.99 [0.96–1.03] | 0.776 |
Household monthly income |
Less than $40 | 551 (91.4) | | | 552 (91.8) | | |
$40 and above | 268 (98.2) | 1.07 [1.04–1.11] |
<0.001* | 261 (96.3) | 1.05 [1.01–1.08] | 0.005 |
Household head |
No | 688 (93.3) | | | 688 (93.3) | | |
Yes | 131 (94.2) | 1.01 [0.96–1.06] | 0.681 | 125 (92.6) | 0.99 [0.94–1.04] | 0.756 |
Ever tested for HIV |
No | 133 (94.3) | | | 133 (95.0) | | |
Yes | 686 (93.3) | 0.99 [0.95–1.03] | 0.644 | 680 (92.9) | 0.98 [0.94–1.02] | 0.307 |
Ever used modern family planning method |
No | 283 (92.5) | | | 279 (91.8) | | |
Yes | 536 (94.0) | 1.02 [0.98–1.06] | 0.392 | 534 (94.0) | 1.02 [0.98–1.06] | 0.233 |
Cervical cancer screening status |
Not screened | 785 (94.1) | | | 774 (93.2) | | |
Screened | 34 (80.9) | 0.86 [0.74–0.99] |
0.046* | 39 (92.9) | 0.99 [0.91–1.08] | 0.923 |
Predictors of intention to screen and willingness to vaccinate daughters against cervical cancer
When all factors were examined simultaneously in relation to intention to screen, respondents whose households earned 40 US dollars and above per month had a significantly higher intention to screen for cervical cancer compared to those who earned less than 40 dollars (adjusted PR = 1.11, 95% CI: 1.03–1.20). Cervical cancer screening status (adjusted PR = 0.81, 95% CI: 0.67–0.99) and knowledge of at least one test for cervical cancer was significantly associated with intention to screen (adjusted PR = 0.92, 95% CI: 0.85–0.98). Among attitude factors, although not statistically significant, respondents who stated that cervical cancer was a severe disease had an 81% higher intention to screen (adjusted PR = 1.81 95% CI: 0.96–3.42) while the prevalence of intention to screen was 37% higher among respondents whose families would approve of children being vaccinated against cervical cancer (adjusted PR = 1.37, 95% CI: 0.83–2.26) compared with their counterparts.
No sociodemographic characteristic was associated with willingness to vaccinate daughters against cervical cancer. Additionally, respondents who knew more than one symptom of cervical cancer had a lower prevalence of willingness to vaccinate daughters against cervical cancer (adjusted PR = 0.89, 95% CI: 0.81–0.98). Although not statistically significant, the prevalence of willingness to vaccinate daughters was over 4 times higher among respondents who stated that cervical cancer screening was important (adjusted PR = 4.36, 95% CI: 0.38–49.2) and over 3 times higher among those whose families would approve of children being vaccinated against cervical cancer (adjusted PR = 3.87, 95% CI: 0.79–19.04) compared with their counterparts. No attitude and health facility factors were associated with willingness to vaccinate daughters against cervical cancer (Table
6).
Table 6
Independent predictors of intention to screen and willingness to vaccinate daughters against cervical cancer
Characteristic | Adjusted PR (95% CI) |
p-value | Adjusted PR (95% CI) |
p-value |
District (Bugiri) |
Mayuge | 1.06 [0.99–1.13] | 0.072 | 1.05 [0.97–1.13] | 0.248 |
Residence (Rural) |
Semi-urban/urban | 1.05 [0.98–1.14] | 0.155 | - | - |
Age in years (25–39) |
40–49 | 1.01 [0.92–1.12] | 0.845 | 1.04 [0.99–1.10] | 0.133 |
Education level (None/primary) |
Post primary | 0.93 [0.84–1.03] | 0.170 | 0.97 [0.92–1.02] | 0.231 |
Religion (Muslims) |
Christians | 0.92 [0.85–1.00] | 0.059 | 0.97 [0.93–1.01] | 0.172 |
Household monthly income (Less than $40) |
$40 and above | 1.11 [1.03–1.20] |
0.004* | 1.03 [0.99–1.07] | 0.149 |
Cervical cancer screening status (No) |
Yes | 0.81 [0.67–0.99] |
0.037* | 1.01 [0.93–1.11] | 0.769 |
Knowledge factors |
Early detection of cervical cancer is helpful (No) |
Yes | 1.07 [0.92–1.24] | 0.407 | - | - |
Knew that one can be vaccinated against cervical cancer (No) |
Yes | 1.00 [0.92–1.08] | 0.998 | 0.99 [0.96–1.04] | 0.959 |
Knew more than 1 preventive measure for cervical cancer (No) |
Yes | - | - | 1.04 [0.99–1.09] | 0.136 |
Knew more than 1 symptom of cervical cancer (No) |
Yes | 0.93 [0.86–1.01] | 0.078 | 0.89 [0.81–0.98] |
0.020* |
Knew at least one test for cervical cancer (No) |
Yes | 0.92 [0.85–0.98] |
0.017* | 0.99 [0.93–1.05] | 0.655 |
Attitude factors |
Cervical cancer is a severe disease (No) |
Yes | 1.81 [0.96–3.42] | 0.068 | 1.36 [0.79–2.30] | 0.258 |
I am at risk of getting cervical cancer (No) |
Yes | 0.89 [0.78–1.03] | 0.127 | 1.04 [0.86–1.27] | 0.660 |
Cervical cancer screening is important (No) | | | | |
Yes | 0.61 [0.34–1.09] | 0.097 | 4.36 [0.38–49.2] | 0.234 |
Only women who are sexually active need cervical cancer screening (Yes) |
No | - | - | 1.02 [0.97–1.06] | 0.479 |
Women who have had sexually transmitted diseases are more likely to get cervical cancer (No) |
Yes | 1.05 [0.97–1.14] | 0.190 | 1.03 [0.97–1.09] | 0.303 |
Chances of curing cervical cancer are better when the disease is discovered at an early stage (No) |
Yes | 0.99 [0.92–1.08] | 0.947 | 0.97 [0.91–1.03] | 0.338 |
Cervical cancer is not a death sentence for most people (No) |
Yes | - | - | 0.99 [0.95–1.04] | 0.790 |
There is much a woman can do to reduce her chances of getting cervical cancer (No) |
Yes | 1.02 [0.95–1.08] | 0.697 | 1.00 [0.97–1.03] | 0.929 |
Women who have cervical cancer will have some symptoms showing it (Yes) |
No | 0.86 [0.71–1.06] | 0.157 | 0.86 [0.72–1.02] | 0.085 |
Cervical cancer runs in families (No) |
Yes | - | - | 0.98 [0.95–1.02] | 0.410 |
Women only need cervical cancer screening tests during child bearing years (No) |
No | 0.99 [0.92–1.06] | 0.802 | 0.97 [0.93–1.02] | 0.228 |
Their family would approve of children being vaccinated against cervical cancer (No) |
Yes | 1.37 [0.83–2.26] | 0.217 | 3.87 [0.79–19.04] | 0.096 |
Health facility factors |
Where health care is accessed (Private facility) |
Government facility | 0.93 [0.82–1.05] | 0.240 | 1.03 [0.87–1.20] | 0.749 |
Where reproductive health care is accessed (Private facility) |
Government facility | 1.11 [0.89–1.39] | 0.351 | 0.95 [0.86–1.05] | 0.347 |
Knew where cervical cancer screening is provided (No) |
Yes | 1.13 [0.97–1.32] | 0.121 | 1.08 [0.96–1.23] | 0.189 |
Distance to health facility where screening is done (5 or more km) |
Less than 5 km | 1.07 [0.98–1.17] | 0.124 | 1.03 [0.98–1.08] | 0.271 |
Discussion
This study assessed the socio-demographic, knowledge, attitudinal and health facility factors associated with women’s intention to screen, and willingness to vaccinate their daughters against cervical cancer in eastern Uganda. Overall, 91% of respondents reported intention to screen for cervical cancer in the subsequent six months. This intention to screen increased to 92% if the service would be offered at an affordable cost, and to 95.9% if provided free of charge. This intention to screen for cervical cancer is higher than the 63% reported by a previous study conducted in southern Ugandan [
18]. Although intention to screen was this high and respondents relatively knowledgeable about cervical cancer and screening [
35], actual uptake of cervical cancer screening in this population of women was very low at 4.8% as reported in a related study [
19]. This therefore calls for an in-depth exploration of the barriers that could be limiting most of these women from accessing cervical cancer screening. In fact, respondents who did not intend to screen majorly stated that screening was neither necessary nor important highlighting the presence of knowledge gaps that should be filled through adequate sensitisation of women to appreciate the severity of the disease and increase their risk perception. Therefore, increasing access to cervical cancer screening services and further education of women is expected to increase uptake rates of screening services which are currently low in developing countries including Uganda.
The target group for HPV vaccinations being prepubescent girls, parental approval is required for the success of vaccination programmes [
24]. In this study, we found a high willingness of 90.4% among women to vaccinate their daughters against cervical cancer. This is in line with proportions of over 90% reported by Kenyan [
36,
37] and Ghanaian [
7] studies. However, these studies majorly targeted urban women at health centres unlike our study that had majority rural participants in the community. This high willingness in our study could have been contributed to by the high acceptability and uptake of vaccines in Uganda [
5], a determinant of HPV vaccine acceptability among parents [
7,
25,
28]. There are also ongoing campaigns by the government of Uganda aimed at HPV vaccinations of girls aged between 9 to 13 years which could have increased awareness of cervical cancer and vaccinations. As there is high willingness to vaccinate daughters, the focus of various stakeholders such as the Ministry of Health and Non-governmental Organisations should be turning this into actual practice through increasing service availability and accessibility by using effective strategies such as schools, health centres, and community based programmes [
5,
8].
In the study, there was a significant association between having higher income and intention to screen against cervical cancer. Moreover, intention to screen increased with possibilities of affordable and free cervical cancer screening which could highlight the cost of the procedure as a barrier as reported elsewhere [
16,
19,
38]. Prior studies have also found associations between higher income and uptake of cervical cancer screening [
17,
39,
40]. This highlights the need to ensure the provision of affordable or free cervical cancer screening services to increase uptake of the service among women in developing countries. We also found that respondents who had already accessed screening, and those who knew at least one test for cervical cancer were less likely to intend to screen in the subsequent six months. It is likely that respondents who knew the screening tests had been screened for cervical cancer as earlier highlighted [
19]. Since these respondents had already been screened, though at various intervals [
19], they could have been reluctant to access screening in the following six months. Indeed, the WHO recommends screening for cervical cancer at 3 year intervals among women aged 30 years and above [
11]. Similarly, the Ugandan Ministry of Health strategic plan for cervical cancer prevention and control 2010–2014 recommends screening for cervical cancer once every three years for HIV negative women, and annually for those who are HIV positive [
6]. Nonetheless, a study in Kenya [
17] found lower intentions to screen among women who had already been screened while a Chinese study reported otherwise [
41]. Respondents who knew more than one symptom of the disease had lower willingness to vaccinate their daughters. It is possible that such respondents were reluctant to take up interventions in cases where they knew how the disease could manifest yet they had not observed these. Indeed, it has been reported that women may for example not access cervical cancer screening because they do not have any signs and symptoms of the disease [
18,
19]. Sensitization campaigns should emphasize the asymptomatic nature of cervical cancer especially during its early stages and encourage women to access cervical cancer services even when they do not have any signs or symptoms of the disease. Among the attitudinal factors, although not statistically significant, respondents whose families would approve of daughters being vaccinated against cervical cancer were more likely to intend to screen for the disease, and more willing to have their daughters vaccinated against it. Study respondents being women, this could indicate a gender influence which has been shown to affect health care decision making in many African households [
42,
43]. For example, previous studies have shown that sometimes women may require approval and financial support from their husbands to seek cervical cancer screening [
18,
42,
43] emphasizing the importance of social influence from important others such as spouses. On the other hand, this finding could indicate the desire for collective decision making among parents especially when it comes to the vaccination of their daughters as reported by another study [
7]. Overall, this underscores the need for involvement of all societal groups especially men in programmes aimed at increasing cervical cancer screening and vaccination.
This study examined intention to screen, and willingness to vaccinate daughters among a majorly rural population, and had a large sample size compared with other sub-Saharan Africa studies. However, some elements of this study for example intention to screen, and willingness to vaccinate daughters could have been affected by the tendency for study participants to give socially desirable responses which could have introduced bias. We also did not assess knowledge about HPV and the vaccine whose relationship with vaccination acceptability would have been relevant to explore, and neither did we assess reasons for willingness to vaccinate daughters among the sampled women. Nevertheless, this study contributes important information regarding intention to screen among women and willingness to vaccinate daughters against cervical cancer and associated factors which can inform future studies as well as cervical cancer programmes.
Acknowledgements
We thank the study participants and research assistants for taking part in the study.