Women’s knowledge and attitudes toward cervical cancer and cervical cancer screening in Zanzibar, Tanzania: a cross- sectional study

Abstract

Background: Cervical cancer is the most common cancer and the leading cause of cancer death among women in Tanzania. Knowledge and willingness of cervical cancer screening are important determinants of prevention services. This study aimed to describe women's awareness about cervical cancer and to explore the attitudes, acceptability and barriers toward cervical cancer screening in Zanzibar, Tanzania, in order to help organizing the forthcoming China-Zanzibar cervical cancer screening program.

Methods: A cross-sectional study was conducted from March to June 2018, involving 1483 women who responded to questionnaires concerning general demographic characteristics, screening willingness and awareness of cervical cancer from 10 districts in Zanzibar. Chi-square tests, analysis of variance, rank sum tests and stepwise multiple regression were conducted using STATA 15.0 software.

Results : The average Total Knowledge Scores(TKS) was 7.83±5.32 on a 23 scale. Education level and family income were positively correlated with TKS (Coef=1.075, 95% CI=0.687-1.462 and Coef=0.810, 95% CI=0.262-1.358 respectively). Previous schistosomiasis history (OR = 24.140, 95% CI= 3.306-176.266) and family genetic disease history (OR = 3.140, 95% CI= 1.644-5.997) were strong predictors of free screening. Women were less likely to be screened freely if they had 7 or more deliveries (OR = 0.300, 95% CI= 0.150-0.598) and were unknown about previous family tumor history (OR = 0.381, 95% CI= 0.218-0.665). As for non-free screening, age and education level were negatively associated while family income was positively associated with willingness to uptake non-free screening; divorced or widowed marriage and unawareness about previous family tumor history were predictors of reluctance to screening while previous disease history was the strong predictor of non-free screening uptake. Among 129 women who were reluctant and 50 who were uncertain to participate in the free screening, 51.4% thought it was unnecessary, 18.44% showed obvious fear and 20.67% were worrying about extra infection.

Conclusions: The findings revealed that the knowledge of cervical cancer was poor. Education level, family income and awareness of previous disease history were the significant influencing factors of screening uptake. Specific awareness programs to increase knowledge and willingness to uptake screening should be designed and implemented in the public without delay.

Background

Cervical cancer, with an estimated 570000 new cases and 311000 deaths in 2018 globally, is the fourth most common cancer and the fourth leading cause of cancer death among women worldwide; however, it is the most commonly diagnosed cancer in 28 countries and the leading cause of cancer death in 42 countries, the majority of which are in Sub-Saharan Africa [1].Tanzania exhibits the sixth highest rate of cervical cancer in the world, with age-standardized incidence reached 59.1 per 100000 women and age standardized mortality reached 42.7per 100 000 women per year. Cervical cancer was responsible for 39% of all newly developed cancers in women and among them around eighty percent presented with advanced-stage and thus was the leading cause of cancer-related deaths among Tanzanian women [1]. The lack of available comprehensive screening programs for cervical cancer helps explain the shockingly high incidence and mortality in those countries and it has already shown that an organized screening program can reduce incidence and mortality by 80%[2].

In Tanzania, due to inadequate personnel and deficiencies in health system infrastructure, cervical cancer prevention remains largely opportunistic, often relying on low-resource visual inspection methods using acetic acid (VIA)[3]. However, reported uptake of even this screening service remains low, suggesting that there are barriers preventing women from being screened[4]. A general lack of awareness and insufficient preparations paid to screening program both contribute to ineffective screening results. A recent study from the Kilimanjaro region of Tanzania reported that only 6% had ever been screened for cervical cancer while the majority of women perceived that they were susceptible to cervical cancer and were willing to accept screening if it were to be available[5]. Thus it is necessary to understand and address the multifaceted health beliefs that are likely to influence women’s willingness to schedule and obtain screening.

In Zanzibar, a semi-autonomous region of Tanzania, information about incidence and mortality of cervical cancer as well as women’s knowledge about cervical cancer has never been reported. Assessing women’s knowledge on cervical cancer will help to take into account the actual scenario and find out approaches to increase perception of cervical cancer or change attitude toward cervical cancer screening and create demand for cervical cancer screening service. The purpose of this study, therefore, was to describe women’s awareness about cervical cancer and to explore the attitudes, acceptability and barriers toward cervical cancer screening (CCS) in a population-based sample of women living in Zanzibar, in order to better organize the forthcoming China-Zanzibar cervical cancer screening program in Zanzibar.

Methods

Study design and Respondents

A cross-sectional survey was conducted from March 2018 to June 2018 among women aged 14–65 years old in Zanzibar. Based on the data from Zanzibar Population Registry, with totally 10 administrative districts involved, a power calculation been used to estimate a required sample size of 200 women from each district, we randomly chose 5 wards from each district and visited 30 women randomly from each ward. Assisted by local volunteers from the 10 districts, we interviewed 1500 women at various community sites in each ward, including mosques, grocery stores, health fairs, community centers and homes. As there were 17 non respondents, totally 1483 participants were involved in our study.

Procedures

The study questionnaire was designed in English, translated and interviewer administered in Swahili, the official language of Zanzibar. All employees received a three-page questionnaire, with the first page explaining the purpose and importance of the study. Trained volunteers give a brief introduction to the purpose of the study before both voluntary oral and written consent was obtained. Participants were assured of complete anonymity in response to the answers provided. Most questions were closed-response and the questionnaire took approximately 30 min to complete. There were not any pre-cervical cancer screening services in the implementing areas during this study, which was a baseline assessment before introduction of screening services. Brief education on the location and function of the cervix was provided during the survey for women who said they had never heard the word before.

Measures

The survey (Appendix A) was developed through the integration of validated questions from both the Cervical-Cancer-Knowledge-Prevention–64 (CCKP–64)[6] and the Cervical Cancer Awareness Measure (CAM) questionnaires [7].The final questionnaire consisted of 33 items of general demographic questions, 3 closed-ended questions that determined attitudes related to screening and 14 closed-ended questions that determined awareness of cervical cancer. Questions were chosen based on their relevance to the cultural setting, considering the diversity of cultural and religious beliefs in Zanzibar. The questionnaire was structured into two sections: Background section mainly includes demographic data, lifestyle related factors such as drinking and eating habits, previous history of diseases, experience of gynecological examination and women’s attitude towards screening. Another section is to assess the knowledge of cervical cancer and cervical cancer screening, using a multiple-choice format. Questions were referred to previous studies [8] with questions on awareness and understanding of cervical cancer and its screening, including signs and symptoms, risk factors and women's attitude toward the disease. The structured questionnaire was used by five trained interviewers. To increase the reliability of the information, the interviewers were trained to administer the questionnaires in a uniform way to prevent their own interpretation of the questions.

In order to assess the overall level of awareness of the participants relating to cervical cancer and the screening, Total Knowledge Scores (TKS) was calculated based on the answers to the questions of the second section. For each correct answer or each positive response to cervical cancer or screening, one score was obtained and the sum of the scores in the questionnaire was 23 scores. A higher score corresponds to greater knowledge of cervical cancer and the screening.

Data analysis

The data were analyzed using STATA Software Version 15. Basic descriptive statistics and frequency calculations were performed on all variables. Chi-square tests，analysis of variance (ANOVA) and rank sum tests were used to analyze the data. Stepwise multiple regression was performed as a supplementary analysis.

Ethics approval and consent to participate

Ethical clearance for this study was obtained from the Zanzibar Medical Research and Ethics Committee （Reference number ZAMREC/0003/APRIL/ 2018）. Informed consent forms were signed by the interviewer indicating that the study objectives were explained to the participants and both verbal and written consent were received. For women aged < 16 years, the consent was given by their parents or care take/partners. Confidentiality was ensured throughout the process of data collection. Analysis was performed using de-identified code numbers rather than participant names.

Results

Socio-demographic characteristics

Characteristics of the participants are shown in Table 1. From the total 1483 women, the mean age was 32.86 years (SD 10.93, range 14 to 65) and 85.5% of the participants were aged 20 to 49 years. Nearly all the interviewees were Muslin region (98.04%). The vast majority of the participants were married or cohabiting (74.58%) whereas14.95% were identified as consanguineous mating. Nearly one quarter (23.40%) of the women had sex experience before 18 years old and the average parity of all respondents was 2.96 with a maximum of 14. Over half (62.04%) had attained secondary level of education and approximately two-thirds (66.01%) lived in a just getting by lives. Most women (80.38%) drunk tap water followed by 16.5% drunk well water and 3.44% drunk pure water. A considerable number of respondents drunk local spice tea frequently (39.04%) or occasionally (27.78%). Approximately one-third (34.66%) of the participants had previous disease history including schistosomiasis history, which accounted 7.28% among all women in the survey. Genetic diseases had affected 15.31% of women in our study and 9.78% of participants were with family cancer history.1304 women (87.93%) were willing to attend free screening program while only 852(57.45%) would uptake the screening at their own expenses. Only 4.38% of the respondents had received a cervical cancer screening before. The average TKS was 7.83±5.32 (range from 0 to 22).

Bivariate models for identification of factors associated with screening and cervical cancer awareness

As presented in Table 2, women’s willingness of screening had been significantly associated with age group, marital status, parity, levels of education, family income, personal previous history of disease, genetic disease and family cancer history. Participants between 25 to 29 years old showed the highest acceptance of free screening (p = 0.003) as well as non-free screening (p = 0.045). With regard to marital status, the Married/Cohabiting group showed higher acceptance than the Divorced/Widowed group (60.58% vs. 48.97%, p = 0.000). Women who had delivered 1~3 children were more likely to attend both two types of screening than the highest parity group (90.74% vs. 78.98%, p = 0.000 and 60.55% vs. 53.98%, p = 0.000 respectively). As to educational level, there was no difference in the acceptance of free screening while women without formal education were more likely to accept non free-screening than the tertiary educated women (64.8% vs. 50%, p = 0.000). Wealthy women were more willing to attend non-free screening than the needy ones (62.5% vs. 50.81%, p = 0.000). Women who had previous disease experience especially schistosomiasis history were more likely to accept both types of screening than those healthy ones (99.07% vs. 85.99%, p = 0.004; 93.52% vs. 51.38%, p = 0.000). Women with genetic disease were more willing to uptake free screening (95.15% vs. 86.35%, p = 0.000) but when it refers to self-paying there was no difference between the two groups. Moreover, women who were unaware of family tumor history were less likely to uptake free screening as well as non-free screening than the others (p = 0.042, p = 0.005).

Knowledge scores of cervical cancer were correlated with marital status, parity, levels of education, age of first sex, family income, personal previous disease, family cancer history and previous screening. Women who were unmarried, nulliparous, who had received tertiary education, who had sex after 24 years old and the wealthy ones scored more in comparison with their counterparts (p<0.05). Women with previous schistosomiasis history were much less aware than women with other disease history (3.62±6.30 vs. 8.62±4.93, p = 0.000). More awareness appeared to be also associated with family cancer history (9.05±5.00 vs. 7.64±5.33, p = 0.004) and previous screening (10.28±4.75 vs. 7.72±5.32).

Multivariate models for identification of factors associated with screening and cervical cancer awareness

In the multivariate logistic regression model of potential predictors of free-screening uptake, previous schistosomiasis history (OR = 24.140, 95% CI = 3.306–176.266) and family genetic disease history (OR = 3.140, 95% CI = 1.644–5.997) were strong predictors of free screening. Women were less likely to be screened freely if they had 7 or more deliveries (OR = 0.300, 95% CI = 0.150–0.598) and were unknown about previous family tumor history (OR = 0.381, 95% CI = 0.218–0.665). (Shown in Table 3)

As shown in Table 4, age and education level were negatively associated while family income was positively associated with willingness to uptake non-free screening; divorced or widowed marriage and unaware about previous family tumor history were predictors of reluctance to screening while previous disease history was the strong predictor of non-free screening uptake.

Table 5 portrays factors that may be linearly dependent on TKS using multiple linear regressions. Among these variables, education level and family income were significant predictors of TKS(Coef = 1.075, 95% CI = 0.687–1.462 and Coef = 0.810, 95% CI = 0.262–1.358 respectively). Single women scored more when compared to married and cohabited women (Coef = 2.147, 95% CI = 0.717–3.577). Women who had 7 and more deliveries were more likely to have a higher score (Coef = 1.366, 95% CI = 0.205–2.527) when compared to those never delivered. In addition, women with family tumor history and cervical screening history were also positively associated with knowledge scores when compared to those without previous history (Coef = 1.070,95% CI = 0.199–1.942 and Coef = 2.398, 95% CI = 1.136–3.660 respectively). At the same time, women who had previous schistosomiasis history and those who were unknown about their previous disease history were associated with lower knowledge scores compared to the healthy ones (Coef = –3.947, 95% CI = –4.989~–2.905 and Coef = –4.054, 95%CI = –6.134~–1.973 respectively). Other variables showed no linear correlation with TKS.

TKS and Distribution by different attitudes to free and non-free screening

As shown in Figure 1, women who were not going to receive either free or non-free screening scored more than the other two groups yet with generally low level among all participants. Of all women sampled, 87.9% were willing to receive free screening and a bit more than half(57.4%) were willing to receive non-free screening; however, of the women who scored 20 or more, nearly all of them(96.4%) were going to take free screening and the most majority (82.1%)would do even at their own expenses.

Barriers to free screening uptake

Figure 2 portrays barriers for free screening, among 129 women who were reluctant and 50 who were uncertain. More than half (51.4%) thought there was no need to do that and about one fifth (18.44%) showed obvious fear about this screening. Approximately another one fifth (20.67%) were worrying about being infected with extra diseases by such examinations.

Women’s awareness of cervical cancer risk factors and warning signs

As for risk factors associated with cervical cancer, less than one third (29.20%) were aware of HPV infection while almost four in ten (39.04%) denied knowing anything about it. There were still lots of women thought that oral contraceptives, condoms usage or even swimming in public pools were risk factors of cervical cancer, with the proportion of 30.68%, 14.03% and 13.42% respectively. (Figure 3A)

Nearly one third (28.41%) thought bleeding during periods should warn of cervical cancer and 32.64% thought bleeding during or after intercourse might also be a warnings sign whereas more than forty percent were unaware of any signs about cervical cancer. (Figure 3B)

Discussion

To the best of our knowledge, this cross-sectional survey research seems to be the first study employing a validated questionnaire to investigate the awareness of cervical cancer and factors affecting the attitude of screening among African women living in Zanzibar, Tanzania. The most important finding from this study indicates that women’s knowledge about cervical cancer was generally inadequate and was persistently associated with education, family income and family cancer history. The willingness of self-paid screening was largely influenced by family income. Our findings also firstly uncovered a strong association between schistosomiasis infection history and attitude to screening participation.

This baseline study highlight the great lack of knowledge about cervical cancer, which is consistent with other studies conducted in Ethiopia and Kenya [9, 10]. The low level of perception towards cervical cancer is likely the most contributing factor to cervical cancer- related morbidity and mortality in Sub-Saharan African countries. The average TKS of our survey respondents was 7.84±5.32 on a 23 score scale with less than 2% scored 20 or above, which was also in accordance with another recently published research among women in Lake Zone Tanzania reporting the median score of cervical cancer knowledge was only 16.67% and only 17.3% scored 50% or more [11]. Our study also revealed that 39.04% of women were completely ignorant about risk factors and meanwhile oral contraceptives (30.68%) was the most frequently recognized as the risk factor of cervical cancer, followed by HPV infection (29.20%), condom use (14.03%) and swimming in public pools (13.42%). The misconceptions reflect women’s excessive worrying about birth control pills and devices and their mismatching with cervical cancer. Another worrisome finding in this study is that the warning signs of cervical cancer were correctly identified only by roughly one third of respondents with nearly half (40.46%) denied knowing anything about it. Our results further support previous studies that women in African countries were sorely lack of knowledge about cervical cancer and this leaves much to be desired [12].

Education level was found to be positively associated with knowledge scores which means low knowledge could be due to low education level and low coverage of cancer awareness initiatives in the country; moreover, we demonstrated that women with family cancer history scored more than the ones without, consistent with previous studies [11,13,14]. This consistency emphasizes the influence of formal education and close experience in understanding cervical cancer. Other factors were also explored that could be associated with the knowledge scores: family income, marital status, multiple deliveries and previous screening. These findings may indicate a complex relationship between health and sociodemographic factors in determining population awareness of cervical cancer. Therefore, multiple policies such as public health education, social media, interventions at healthcare facilities and by community health workers are required to improve the knowledge of cervical cancer as it is a determinant of screening utilization and an important component of cervical cancer prevention.

Interestingly, our study found women who were reluctant to be screened scored more than the ones who were willing to undergo screening, which is in contrast with previous studies that knowledge of screening was directly and positively associated with screening intention [15, 16]. This may be because the generally quite low cognitive levels tend to be in combination with misunderstandings of cervical cancer and screening thus the genuine correlation between women’s awareness and their willingness to screening couldn’t be revealed in our study. However, when we referred to those scored 20 and above, almost all of them expressed their willingness to participate in the screening program even with self-paying. Such findings further indicate the much-needed improvement of public’s awareness would be followed by a greater acceptance of screening.

As shown in our study and previous ones, finance was an important affecting factor of screening uptake. Free screening would be accepted by the majority participants while 34.89% (455/1304) would give up if it needs to pay. The main reason women refused to participate non-free screening was for economic sake. In addition, we also revealed that family income was another noteworthy affecting factor of self-paying screening. These are unsurprising as most respondents were of low socioeconomic status and the expenditure for screening may be an added strain.

Marital status was revealed to be a significant predictor of screening uptake. Women who were married had a higher acceptance of screening than those divorced or unmarried and the differences were much more significant when it turns to self-paying screening. A recent study by Nwabichie CC et al [17] also demonstrated that married women were at 2 times (AOR 2.257, 95%CI 1.006–4.361) more likely to have a good uptake of screening compared to the unmarried. This might be due to spousal support and one study in Tanzania [18] has indicated that women who received support from their husbands were more likely to receive cervical screening. There is another study [19] also pointed that spouse may hinder cervical cancer screening because of their ignorance and nonsupport. Therefore, more efforts are required to engage the community including men in promoting awareness of cervical cancer and prevention practices. Some small educational movies, health talks in communities and integration of health awareness themes into popular television and radio dramas might be effective in such promotion and prevention [20, 21].

Although schistosomiasis has been reported to be associated with cervical cancer in a few studies, the association between history of schistosomiasis infection and attitude towards screening has not been reported yet. As shown in previous studies, schistosomiasis is an important and highly prevalent helminthic infection mainly represented with vaginal discharge and abnormal bleeding as female genital involvement. These nonspecific symptoms are quite possible to make women more suspicious about cervical cancer and have greater acceptance of screening. This can partially explain the finding that women with previous schistosomiasis infection was a significant predictor of any type of screening in our study. Another reason may be because women who have been diagnosed with schistosomiasis infection were those who could have the access to medical resources; they are more likely to participate screening than those who lived in the bottom and have no access to medical services.

The major barrier toward free screening identified among Zanzibar interviewees was the misconception that women thought it was not necessary for them to uptake screening because they have no symptoms or discomforts, which is unsurprising, given the women’s poor awareness of cervical cancer screening. Many women also mentioned fear of abnormal results and pain of screening. Worrying about been affected is another common barrier. One study conducted in Addis Ababa, Ethiopia had similar findings, in that the most frequently mentioned barrier was women were feeling healthy and thought it was unnecessary, followed by perceiving fear of positive results and pain of the screening [9]. These results suggest an urgent need to disseminate knowledge about cervical cancer and its association with screening, and they further suggest that campaigns to improve cognition of cervical cancer and screening are likely to be effective at breaking through those barriers.

The main strength of our study is the situation-based use of mixed refinement of previous questionnaires. Data was also collected via face to face interviews and double check, minimizing the likelihood of misunderstanding the questions and yielding errors. Moreover, the study was conducted in all districts of Zanzibar including remote rural areas, which could to some extent represent the cognition and attitude towards cervical cancer and screening in the general population in Zanzibar. Another advantage was that we firstly found schistosomiasis infection was a significant positive predictor for cervical cancer screening uptake. A limitation of this study was that most information was self-reported, which might have caused over or under-estimation of certain variables. In addition, our analyses were cross-sectional and only implied correlation and further research are needed to untangle casual associations to identify key modifiable factors and to assess the effectiveness of different strategies to improve awareness of and willingness to participate in cervical cancer screening in Zanzibar.

Conclusion

Our results point to an urgent need for education and intervention to raise awareness of cervical cancer and willingness to uptake screening. Improvement of enabling factors such as increase the awareness of cervical cancer and screening by strengthening education and publicity may help promote cervical cancer awareness and participation in the upcoming cervical cancer screening program in Zanzibar and potentially decrease the enormous social and economic burden caused by cervical cancer locally.

Declarations

Acknowledgements

We acknowledge and appreciate the cooperation of study participants as well as Mnazi Mmoja hospital administrative staff for their valuable contribution.

Funding

This study was funded by National Natural Science Foundation of China (81701475).

Availability of data and materials

The datasets analyzed during the current study are not publicly available to protect the participants’ anonymity. But can be freely available from the corresponding author on reasonable request.

Authors’ contributions

Qiao Weng designed the study, participated in data collection statistical analysis and manuscript writing. Jie Jiang participated in data analysis. Fatma Mrisho Haji and Lamlet Hassan Nondoparticipated in data collection. Huaijun Zhou provided guidance in designing the study, statistical analysis and reviewed the manuscript for intellectual content. All authors read and approved the final manuscript.

Competing interests

The authors declared that they have no competing interests.

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