Of 165 men we approached for potential participation, 125 were eligible for inclusion and willing to participate (see Appendix 2 for list of reasons men were screened out; the most common reason for nonparticipation was being unmarried or not having a long-term partner [n=23], followed by never having heard of cervical cancer [n=12] and refusing to participate in the study [n=5]). Five participants were unaware of their partner’s screening status and were excluded from all analyses, as they could not be combined with either group for main comparisons and the small number of men in this group prohibited a subgroup analysis of those unaware of screening status.
Among the 120 respondents who were aware of their partner’s screening status, 73 (61%) reported having a primary partner who had previously screened for cervical cancer, and 47 (39%) reported having an unscreened primary partner (Table 1). Approximately one-fifth of all respondents (n=25, 21%) reported having multiple sexual partners in the past 12 months and 8% (n=10) reported currently having multiple wives. The mean age of respondents with a screened partner was 47 years, versus 42 years among men with an unscreened partner. Primary female partners who were reported to be screened were significantly older (mean age 40 years) than unscreened primary female partners (mean age: 34 years, p<0.01). A higher percentage of men with screened partners were HIV-positive (n=26, 55%), although this was not a significant difference (p=0.07). These differences persisted in age-stratified models, but were more prominent among men under the age of 45 (data not shown).
Experiences and knowledge of cervical cancer
Overall, 21% of men (n=25) reported knowing someone who had died from cervical cancer and 10% (n=12) knew someone who had survived cervical cancer (Appendix 3). Approximately 61% of all respondents (n=73) felt that cervical cancer is more dangerous than HIV, and nearly 90% (n=106) agreed that their primary partner was at risk of developing cervical cancer throughout her life. A higher proportion of men with previously-screened partners knew someone who had died or survived cervical cancer, agreed that cervical cancer is more dangerous than HIV, and expressed that their partner was at risk, compared to men whose partners had never been screened , although these were not significant associations.
On average, men responded correctly to 4.2 out of 8 questions about cervical cancer risk factors (52% correct response rate) (Appendix 4) and there was no significant difference by partner screening status (data not shown). Although all respondents answered correctly to certain items (having multiple sexual partners is a risk factor for cervical cancer), other questions were rarely answered correctly (e.g., only 6% of men knew that applying herbs to the vagina is not a risk factor for cervical cancer) (Figure 1a). There was no significant association between having a screened partner and knowledge of any individual risk factor.
Figure 1: Correct response to knowledge questions about cervical cancer risk factors (Figure 1a) and screening and treatment (Figure 1b)
During qualitative interviews, many men spoke about cervical cancer risk factors relating to sexual behavior. The correlation between multiple sexual partners and cervical cancer risk was often mentioned, especially by relatively younger men whose partners had been screened; and younger men with higher GEM and knowledge scores commonly mentioned unprotected sex (both with one’s primary sexual partner, and with other partners) as a risk factor.
“A man should be faithful to his wife and avoid promiscuity. A woman also has the same responsibility.” (42, partner screened)
“[Wife and husband] should have protected sex so that they do not get any sexually transmitted diseases from each other.” (43, partner screened)
Respondents expressed that both men and women should maintain genital cleanliness in order to prevent cervical cancer. This response was more common among men whose partners had not been screened. Circumcision was seen as a way to be more hygienic.
“It is said that sometimes uncleanliness can cause the cervical cancer, so the circumcision brings cleanliness that will also help in the prevention.” (35, partner not screened)
Knowledge and beliefs about screening
Men responded correctly to an average of 5.8 of 8 questions about screening and treatment services (correct response rate of 72%) (Appendix 4); although men with screened partners had a slightly higher score (74%, versus 69% for men with unscreened partners) this was not a statistically significant difference. Correct responses to individual items ranged from 33% (following treatment, women should not have sex for 4 weeks) to 100% (screening should take place even if there are no symptoms) (Figure 1b). The only questions with responses significantly associated with whether a man’s partner had been screened were the availability of screening at the study site (OR 2.58, 95% CI: 1.11 - 5.98), and the need for abstinence following treatment (OR 4.25, 95% CI: 1.62 – 10.85) (Appendix 3).
Despite largely correct responses to the survey questions about cervical cancer screening practices, when asked to describe screening in their own words, the majority of men could not provide accurate descriptions.
“She just said that I went to the hospital, they tested me and they have found that I am okay. So I did not go into detail because I was just happy my wife was okay.” (51, partner screened)
Of those who provided a description of the screening process, most men reported knowing that it includes a vaginal exam; and some men – especially those whose partners had previously been screened and with higher GEM scores – knew that screening is conducted with an instrument or machine (sometimes mentioning that it is metal); and some stated that vinegar is involved.
“I don’t really know about the process, I only heard that the doctors have access to the woman’s private parts and screen inside there.” (35, partner not screened)
“She just said they have a machine that they insert and start scanning to check if she has the disease or not.” (47, partner screened)
Many men did however note that screening is important because cervical cancer is dangerous (deadly) unless it is caught early – and older men whose partners had been screened were particularly likely to say this. No men said that screening was unimportant.
“The disease is dangerous because when it is detected early it is treatable, but if discovered at a later stage, it can cause death.” (56, partner screened)
“If the wife is not screened but has cervical cancer, then it means their family will be affected. Because of that women need to be screened.” (56, partner screened)
Men mentioned numerous benefits related to cervical cancer screening -- primarily, that screening is the only way to detect problems related to cervical cancer, unlike other health conditions which can be assessed using other diagnostic or laboratory tests. This was more often mentioned among men whose partners have previously been screened.
“The process is good because they are using instruments to see where eyes cannot see, where there is a problem.” (53, partner screened)
“It is the only procedure to know whether a person has the disease or not.” (29, partner not screened)
After hearing a brief description of screening, men were asked whether they were comfortable with the procedure or with the idea of their partner being screened. No respondent said that he was uncomfortable or that he would be uncomfortable with his female partner getting screened. However, a fewer men had hesitations about their female partner being screened by a male provider. The most common reason for this concern was general modesty and shyness. This was more typically mentioned by older men and those with below-median knowledge scores.
“For a man and a woman being in a room, and one person being naked, it becomes embarrassing.” (43, partner not screened)
Some respondents were also concerned that male providers may have or develop sexual feelings toward their partners due to nudity during the screening process. These were mostly men with lower knowledge scores, and included men with partners who had, and had not, been screened.
“Sometimes a male doctor might perform the process, so they need to be able to restrain their urges as they might be tempted to sleep with the women.” (44, partner screened)
“I have heard that male doctors have sexual relations with female patients. If men hear that their wives will be undressed and put on an exam table by a male doctor… we know that once a man sees a woman naked they will want to have sexual intercourse with her. Because of that men hesitate to tell their wives to get screened for cervical cancer.” (54, partner not screened)
Most men, however, were comfortable with male providers performing the procedure. Many pointed out that you do not get to choose the gender of your provider for other procedures, and that providers are professionals with a code of conduct. These comments were more common among men whose partners had previously been screened.
“If I contract an STI, even a female doctor is at liberty to check my private parts in order to help me.” (44, partner screened)
“Doctors learn confidentiality in their work, and have a responsibility to do their job. It is not like a female doctor is supposed to treat female patients only.” (47, partner screened)
Some men (mostly younger men) were concerned about pain from the procedure or that screening was dangerous. This was reported by men with and without screened partners, and by men with approximately average knowledge scores. Several men felt that such pain is necessary, and compared this to discomfort during an injection.
“Because the body is soft and the metal is hard, it can injure the sex organ of the woman” (43, partner not screened)
“At the hospital we also get injections and you prepare to feel pain but what can you do” (57, partner not screened)
It was more common, however, for men to say that they did not believe screening was painful for women – particularly men whose wives had previously been screened, and men with higher knowledge scores. Some men specifically said that the instrument would not be allowed if it were painful; and that providers would not implement a painful procedure. Others noted that their wives had specifically said it was not painful.
“I think that the doctors are specialists and when they insert the metal they do it in a way that the patient will not feel pain” (41, partner not screened)
“I heard about the pain from other people but when my wife came back from being screened, she said they inserted an instrument but she did not say anything about the procedure being painful” (50, partner screened)
Decision-making about screening
In response to questions about household decision making, approximately 30% of all respondents said that he alone makes decisions about his female partner’s health care. Though the association was not significant, 38% of men with an unscreened partner and 26% of men with a screened partner stated that he alone should make decisions about cervical cancer screening and treatment (Table 2).
When asked to describe what role men should play in supporting their partner for cervical cancer screening, many (especially those with above-average GEM scores) said that they should provide encouragement.
“The husband has a very important responsibility because he has the capacity to encourage the woman to get tested more often for cervical cancer.” (46, partner screened)
Some respondents also noted that they should escort their partners to the hospital for screening. These men were mostly young and had partners who had been screened previously.
“Men need to protect their wives by taking their wives to get screened for cervical cancer.” (54, partner not screened)
Another role for men was in having conversations with their partners around cervical cancer, specifically regarding risk factors, the screening process, and test results. This role was discussed by men with both low and high GEM scores, and was mentioned more often by respondents with higher than average knowledge scores.
“This should be treated as a family problem and discussed in order to prevent new cases of infection.” (42, partner screened)
“They have a huge role of explaining to them the dangers of the cervical cancer, and that it is easy to get help from the hospital when the symptoms are detected, and this may protect her from the dangers of it.” (52, partner not screened)
Gender norms and screening
Men with screened partners exhibited significantly more equitable gender beliefs on average than men with unscreened partners (mean GEM score of 10.8/16 vs. 9.3/16, p<0.05) (Table 3). This score difference was seen largely in the GEM Sex sub-domain, particularly among younger men (under 45 years old) (7.0/10 vs. 5.6/10, p<0.05).
The single GEM element most strongly associated with having a screened partner was disagreement with the statement “It is a woman’s responsibility to avoid getting pregnant” (OR=2.69, 95% CI: 1.22-5.90, p<0.05) (Appendix 5). Other items with a strong and significant association were “Women who carry condoms are ‘cheap’” (OR=2.18, 95% CI: 1.03-4.62, p<0.05) and “There are times when a woman deserves to be beaten by her partner” (OR 1.98, 95% CI: 1.01-4.96, p-value<0.05).
In a model that included covariates for age and education level, the GEM sex sub-domain score was significantly associated with having a screened partner, with an adjusted OR of 1.44 (95% CI: 1.02-2.02, p<0.05) (Table 3). There was not a significant association between cervical cancer knowledge score and partner screening status in the multiple variable model.