Prevalence and Determinants of Cervical Cancer Screening Uptake among Women Attending Maternal and Child Health Services in Northeastern Uganda: a Cross-Sectional Study

doi:10.21203/rs.3.rs-4830702/v1

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Research Article

Prevalence and Determinants of Cervical Cancer Screening Uptake among Women Attending Maternal and Child Health Services in Northeastern Uganda: a Cross-Sectional Study

https://doi.org/10.21203/rs.3.rs-4830702/v1

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Background

Cervical cancer is a significant health issue globally, particularly in less developed countries like Uganda. Despite efforts to improve screening programs, uptake remains low in regions like Karamoja in Uganda. This study aimed to assess the prevalence of cervical cancer screening and associated factors among women aged 25–49 at Moroto Regional Referral Hospital.

Methods

Using quantitative and qualitative methods, data was collected from March to April 2023 from 276 women. The multivariable logistic regression was conducted to assess the factors associated with cervical cancer screening. Data analysis was conducted using STATA15. For qualitative data, an in-depth interview was conducted, and a minimum of thirty participants were interviewed. Then, they were thematically analysed using Atlas ti. 21.

Results

The prevalence of cervical cancer screening among women attending maternal and child health services was 47% (130/276). Upon adjusting in the multivariable logistic regression, we observed that having a primary level of education [AOR 2.0, 95%CI: (1.2–4.9, P < 0.018)] and having given birth to more than four children (AOR 5.0, 95% CI: (1.1–23.1, P < 0.039)) were associated with higher odds of undergoing cervical cancer screening. Identified barriers included low knowledge and awareness of Cervical Cancer and Cervical Cancer screening, extended waiting times, and the influence of healthcare providers.

Conclusion and Recommendation:

The study finds low cervical cancer screening rates, below the 70% target. Factors like education, number of children, and awareness predicted screening uptake. It suggests tailored education for uneducated women and more screening for those with fewer children.

Prevalence

cervical cancer

and Maternal and Child Health

Cervical cancer remains the fourth most common cancer among women globally, with 266,000 deaths every year and 87% mortality occurring in less developed countries (1) Most of the morbidity and mortality occur in the developing world due to a lack of access to appropriate Pap screening facilities (2). Cervical cancer has the greatest incidence and mortality rates in Africa, with Eastern and Southern Africa having the highest rates (3). According to Okoye and others, it is predicted that cervical cancer incidence and death will continue to climb in Sub-Saharan Africa (SSA) for the next 20 years (3). Notwithstanding its morbidity and mortality, cervical cancer and its treatment carries great social and economic consequences on cancer patients, families and countries. It is also associated with poor quality of life, increased treatment expenses and decreased productivity (4)

To prevent and control cervical cancer, the World Health Organization (WHO), government health ministries, and non-governmental organisations have put in place several initiatives, as noted by Kemper and others (5). Key among these is the screen-and-treat technologies, such as visual inspection with acetic acid (VIA) followed by cryotherapy and/or Loop Electrosurgical Excision Procedure (LEEP), which have been successfully adopted in low- and middle-income countries (LMICs). These technologies enable mid-level providers to offer screening and treatment during primary care (5).

In Uganda, the guidelines for cervical cancer screening (CCS) advocate for a ‘see-and-treat’ approach where women aged 25 to 49 years are screened using VIA and treated with cryotherapy (6). However, WHO recommends using HPV DNA detection, which suggests a regular screening interval of every 5 to 10 years as the primary screening test rather than VIA or cytology screening approaches for women and a national target coverage of 70% (7).

Despite these efforts at the national level to prevent cervical cancer, only about 5–30 percent of women have ever been screened in Uganda (8). These challenges have partly been linked to a limited budget for health, characterised by too many competing priorities with other public health problems such as malaria, TB, and HIV, and a lack of information and awareness(4). In addition to health system barriers, studies done by healthcare workers in tertiary hospitals in Eastern Africa have also found that the majority of healthcare workers lack adequate knowledge of cervical cancer (8). Furthermore, there is also a paucity of data on the prevalence and factors associated with the uptake of cervical cancer screening in some parts of Uganda, like Karamoja, particularly among the nomadic Karamojong, who move from one place to another in search of pasture for their animals. This is a unique population in Uganda, which presents a great challenge to healthcare service delivery and coverage for programs like immunisation and screening due to their mobile way of settlement. Because of this, cervical cancer screening uptake has remained lower than the anticipated national target for women in Karamoja in 2019, according to the DHIS2. According to the DHIS2 aggregated figures of 2020/2021, the prevalence of cervical cancer screening among women of reproductive age for Moroto Regional Referral Hospital (MRRH), which is the main screening centre in Karamoja, was reportedly at only 35%, which was much lower than the national target 70% (7). This low uptake of cervical cancer screening remains a challenge despite the guidelines from the National Strategic Plan for Cervical Cancer Prevention and Control (2010–2014). Therefore, we needed to assess the prevalence and the contributing factors for the low prevalence of cervical cancer screening in this part of the region. Despite many interventions, like conducting screening outreaches by non-governmental organisations like Reproductive Health Uganda, the prevalence of cervical cancer screening is still low (9). Understanding the prevalence and the factors associated with low uptake of cervical screening in this unique population was key to informing prevention intervention in this population. Therefore, we conducted a cross-sectional study to assess the prevalence and factors associated with the uptake of cervical cancer screening among women attending maternal and child health services in Moroto Regional Referral Hospital (MRRH).

Study Design

The study was a descriptive cross-sectional study using both quantitative and qualitative approaches to data collection and analysis.

Study Setting

The study was conducted at Moroto Regional Referral Hospital Postnatal Clinic (PNC), where maternal and child health services like cervical cancer, immunisation, and family planning are offered. The hospital has a bed capacity of 230 and serves a unique nomadic population whose lifestyles are characterised by moving from one place to another looking for pastures.

The district borders Kaabong District to the north, Kenya to the east, Amudat District to the south, Nakapiripirit District to the southwest, Napak District and Kotido to the west. Moroto Town is where the district headquarters is and is located at the foot of Mt. Moroto. The town is approximately 213 kilometres (132 min) by road from Mbale City. This is about 434 kilometres (270 min) by road northeast of Kampala, the capital city of Uganda.

Study Population

Women aged 25–49 who attended postnatal clinic at Moroto Regional Referral Hospital were considered. This age group was preferred based on the guidelines for cervical cancer screening in Uganda.

Sample Size Estimation

The sample size determination for this study was done based on the Kish Leslie (1965) single population proportion formula, with parameters set as follows: (Z1-α) = 1.96, p = 20.6% (proportion of women screened for cervical cancer based on a prior study), and a margin of error of 5%. Consequently, the computed sample size was 251. To accommodate potential non-responses, a 10% non-response was added, resulting in a final sample size of 276.

However, for the qualitative data, in-depth interviews were conducted with a total of 30 women, comprising 15 women who had undergone cervical cancer screening and 15 who had not.

Sampling Strategy

The study employed a simple random sampling approach to select women attending postnatal clinics. The sampling frame consisted of extracts of names retrieved from the outpatient register available at the postnatal clinic. Using random numbers, our participants were chosen from these lists to ensure an unbiased representation. To refine the sample, we utilised a filtering process whereby we excluded individuals’ women who did not meet the study's eligibility criteria. The selected participants formed the basis for data collection, which was conducted by trained research assistants who were mainly midwives working at the Moroto Regional Referral Hospital. However, for the qualitative phase, sampling of participants was conducted using convenient sampling where 15 women who were screened and 15 who were not screened and were easily accessible and willing to participate in the study were approached and recruited by the research assistant.

Measurements of Variables

Dependent variable: The dependent variable for this study was cervical cancer screening uptake. This was measured on a dichotomous scale (Yes/No). Screened respondents were women who responded, ‘Yes’ to the question ‘Have you ever undergone screening for cervical cancer (VIA or Pap smear test) in the past?’ or otherwise. The independent variables included health system-related factors, sociocultural factors, individual attitudes, perceptions, and socio-demographic factors.

Data collection techniques

The study utilised both quantitative and qualitative data collection techniques. For quantitative data, a semi-structured questionnaire was used to capture primary data on factors associated with cervical cancer screening. The questionnaire had the following sections: the respondents’ Socio-demographic variables, system-related factors, individual attitudes and perceptions on cervical cancer screening, and uptake of cervical cancers. Trained research assistants who were well conversant in Ngakarimojong and English collected the data. The original tools written in English were translated into the Ngakaramojong language by two natives conversant in both English and the local language. A final translation into Ngakaramojong was then performed, and the meanings were checked for accuracy and preservation.

For the qualitative data, an in-depth interview guide was used to interview women to gather women’s perceptions regarding barriers and factors associated with the uptake of cervical cancer screening. The interviews were audiotaped and transcribed for analysis.

Data Management and Analysis

Data was checked for accuracy and kept under a key and lock file to prohibit leakages of participant’s information. Data cleaning was conducted using Excel and Stata version 15 software.

Data analysis

The quantitative data was analysed using STATA version 15 software. The analysis was conducted at three levels: univariate, bivariate, and multivariate. The participants' characteristics, factors, and level of cervical cancer screening uptake were described using summary statistics, where categorical variables were presented as frequencies and percentages. In contrast, continuous variables were presented in terms of mean and standard deviation for normally distributed variables and median and interquartile ranges for non-normally distributed variables. The association of independent variables with cervical cancer prevention screening uptake was assessed using a bivariate analysis employing the chi-square and Fischer's exact tests. Variables which were found significant at p < 0.05 at the bivariate level were selected for multivariate logistic regression. Multiple logistic regression was used to determine the predictors of uptake of cervical cancer screening. The statistical significance level was set at 0.05.

For the qualitative data, a deductive analysis was employed following thematic framework analysis procedures to explore the attitudes and perceptions of participants on cervical cancer screening. We started by transcribing the data, followed by reading the transcript for familiarisation, categorisation, initial coding, searching, reviewing, refining, and naming themes to produce the report. Atlas. ti 23 was used to classify the nodes as free and tree nodes, and based on this, a final thematic model was developed and summarised as thematic codes.

Socio-demographic information

The study enrolled 276 mothers with a of 29.1 years and a standard deviation of 5.8 years. Among these, the majority, 61.6% (170/276), fell within the age bracket of 25 to 29 years and were married, constituting 89.9% of the total. The preeminent occupation among them was that of a housewife, with 76.1% identifying as such. Half of the respondents disclosed having engaged in their inaugural sexual encounter prior to turning 18 years, accounting for 48.2% (133 out of 276) of the sample size Table 1

Table 1. Socio-Demographic Information

Variable	Frequency n=276	Percentages (%)
Age	Mean 29.1, SD 5.8
Age category (completed years)
25-29	170	61.6
30-39	89	32.2
40-49	17	6.2
Marital Status
Married	248	89.9
Separated/Divorced	6	2.2
Single	20	7.2
Widowed	2	0.7
Level of education
No formal Education	65	23.6
Primary	94	34.1
Secondary	87	31.5
Tertiary	30	10.9
Employment status
Employed	28	10.1
Housewife (married and handling domestic work without any pay)	210	76.1
Self-employed (Working independently or managing their own business)	30	10.9
Student	8	2.9
Religion
Anglican	56	20.3
Catholic	180	65.2
Muslim	25	9.1
Others	5	1.8
Pentecostal	10	3.6
Distance from home to the health facility
<=5kms	252	91.3
>5kms	24	8.7
Age at first sexual intercourse (Complete years)
<18	138	50.0
>18	138	50.0
Number of children
0	16	5.8
1-2	133	48.2
3-4	75	27.2
>4	52	18.8

Prevalence of cervical cancer screening uptake among women attending maternal and child health services

The prevalence of cervical cancer screening among women attending maternal and child health services is 47% (130/276). Among the 276 maternal participants enrolled, 53% (130/276) had never taken up cervical cancer screening Figure 1.

Figure 1. Ever been screened for cervical cancer

Within the scope of this investigation, the analysis focuses on the timing of the most recent cervical cancer screening test among a subgroup of mothers who had undergone such screening. This particular subset comprises 130 participants. Among them, 43 individuals (constituting 33.1%) had undergone the screening within the past year, 46 individuals (accounting for 35.4%) had done so two years ago, and 38 individuals (equivalent to 29.2%) reported having the test conducted more than three years ago and there to be considered to have not done screening because in Uganda was done after every three years.

The study found that 79.2% (109/130) of the mothers received cervical cancer screening, it was administered by female healthcare providers, while male providers administered 14.6% (21/130).

Among those aware of cervical cancer screening, 57.5% (84/130) underwent the procedure, while 42.5% (62 mothers) did not. Among mothers not informed by healthcare workers, all 62 (100%) did not participate in screening.

4.2. Bivariate Analysis

4.2.1 Socio-Demographic Information and Cervical Cancer Screening

We used a chi-square test to assess the relationship between socio-demographic factors and the likelihood of women being screened for cervical cancer and age of the patients, level of education, number of children a mother had were significantly associated with uptake of cervical cancer screening.

The age of participants was significantly associated with cervical cancer screening uptake (p = 0.002). Among women aged 25-29 years, 39.4% had been screened for cervical cancer, while 56.2% of those aged 30-39 years and 76.5% of those aged 40-49 years had undergone screening.

There was a significant association between the level of education and cervical cancer screening uptake (p = 0.002). Among women with no formal education, 40.0% had been screened, compared to 59.6% of those with primary education, 34.5% of those with secondary education, and 60.0% of those with tertiary education.

The number of children a woman had was significantly associated with cervical cancer screening uptake (p = 0.001). Among women with no children, 25.0% had been screened, while 36.8% of those with 1-2 children, 57.3% of those with 3-4 children, and 65.4% of those with more than 4 children had undergone screening Table 2.

Table 2. Socio-Demographic Information and Cervical Cancer Screening

Variable	Total n=276(%)	Ever been screened for Cervical Cancer		P-value
		No n=146(%)	Yes n=130(%)
Age category (completed years)				0.002
25-29	170(61.6)	103(60.6)	67(39.4)
30-39	89(32.2)	39(43.8)	50(56.2)
40-49	17(6.2)	4(23.5)	13(76.5)
Marital Status				0.496
Married	248(89.9)	133(53.6)	115(46.4)
Separated/Divorced	6(2.2)	3(50.0)	3(50.0)
Single	20(7.2)	10(50.0)	10(50.0)
Widowed	2(0.7)	0(0.0)	2(100.0)
Level of education				0.002
No formal Education	65(23.6)	39(60.0)	26(40.0)
Primary	94(34.1)	38(40.4)	56(59.6)
Secondary	87(31.5)	57(65.5)	30(34.5)
Tertiary	30(10.9)	12(40.0)	18(60.0)
Employment status				0.062
Employed	28(10.1)	10(35.7)	18(64.3)
Housewife (married and handling domestic work without any pay)	210(76.1)	112(53.3)	98(46.7)
Self-employed (Working independently or manages their own business)	30(10.9)	17(56.7)	13(43.3)
Student	8(2.9)	7(87.5)	1(12.5)
Religion				0.977
Anglican	56(20.3)	29(51.8)	27(48.2)
Catholic	180(65.2)	94(52.2)	86(47.8)
Muslim	25(9.1)	14(56.0)	11(44.0)
Others	5(1.8)	3(60.0)	2(40.0)
Pentecostal	10(3.6)	6(60.0)	4(40.0)
Distance from home to the health facility				0.423
<=5kms	252(91.1)	130(89.0)	122(93.8)
>5kms	24(8.9)	16(11.0)	8(6.2)
Age at first sexual intercourse (Complete years)				0.228
<18	138(50.0)	68(49.3)	70(50.7)
>18	138(50.0)	78(56.5)	60(43.5)
Number of children				0.001
0	16(5.8)	12(75.0)	4(25.0)
1-2	133(48.2)	84(63.2)	49(36.8)
3-4	75(27.2)	32(42.7)	43(57.3)
>4	52(18.8)	18(34.6)	34(65.4)

Individual attitude and perception of Cervical Cancer

The HIV status, as self-reported by participants, was significantly associated with cervical cancer screening uptake (p = 0.001). Among women who reported being HIV-negative, 34.1% had been screened for cervical cancer, whereas 89.2% of those who reported being HIV-positive had undergone screening.

The language commonly used by health workers was also significantly associated with cervical cancer screening uptake (p = 0.024). Among women who reported that English was commonly used, 50.5% had been screened, whereas 33.3% of those who reported that Ngakaramojong was commonly used had undergone screening.

Women's ability to read and write showed a significant association with cervical cancer screening uptake (p = 0.044). Among women who were unable to read and write, 37.0% had been screened, while 50.7% of those who were able to read and write had undergone screening.

The perception of whether one's religion accepted cervical cancer screening did not show a significant association with screening uptake (p = 0.180). However, the majority of participants (99.3%) believed that their religion accepted cervical cancer screening Table 3.

Table 3. Individual attitude and perception of cervical cancer

Variable	Total n=276(%)	Ever been screened for CERVICAL CANCER		P-value
Variable	Total n=276(%)	No n=146(%)	Yes n=130(%)
HIV status(self-reported)				0.001
Negative	211(76.4)	139(65.9)	72(34.1)
Positive	65(23.6)	7(10.8)	58(89.2)
Language commonly used by health workers				0.024
English	222(80.4)	110(49.5)	112(50.5)
Ngakaramojong	54(19.6)	36(66.7)	18(33.3)
Religion accepts cervical cancer screening				0.180
No	2(0.7)	2(100.0)	0(0.0)
Yes	274(99.3)	144(52.6)	130(47.4)
Able to read and write				0.044
No	73(26.4)	46(63.0)	27(37.0)
Yes	203(73.6)	100(49.3)	103(50.7)
Weekly income				0.313
<10000	226(81.9)	125(55.3)	101(44.7)
10000-50000	39(14.1)	17(43.6)	22(56.4)
50000-100000	11(3.9)	4(36.4)	7(63.6)

System-related factors and Perception of cervical cancer

Receiving information regarding cervical cancer screening (CCS) emerged as a crucial factor significantly associated with screening uptake (p = 0.001). Among women who had received information about CCS, a substantial 61.0% had undergone screening. In stark contrast, none of the women who had not received any information had been screened. This underscores the pivotal role of education and awareness campaigns in promoting cervical cancer screening among this population.

The individuals responsible for making healthcare decisions (p = 0.007). Women who made healthcare decisions themselves, either independently or in conjunction with their partners, exhibited higher screening rates compared to those whose healthcare decisions were made by their partners or others. This highlights the importance of women's autonomy and involvement in healthcare choices as a positive driver for cervical cancer screening Table 4

Table 4. System-related Factors and Perception of CC

Variable	Total n=276(%)	Ever been screened for Cervical Cancer		P-value
Variable	Total n=276(%)	No n=146(%)	Yes n=130(%)	P-value
Accept a male Health worker to perform CCS				0.150
No	29(10.5)	19(65.5)	10(34.5)
Yes	247(89.5)	127(51.4)	120(48.6)
Trust health worker				0.372
No	4(1.4)	3(75.0)	1(25.0)
Yes	272(98.6)	143(52.6)	129(47.4)
Allowed to access female health workers of one’s choice				0.128
No	9(3.3)	7(77.8)	2(22.2)
Yes	267(96.7)	139(52.1)	128(47.9)
Ever received any information regarding ccs				0.001
No	63(22.8)	63(100.0)	0(0.0)
Yes	213(77.2)	83(39.0)	130(61.0)
Who usually decides on one’s healthcare				0.007
My partner/husband alone	7(2.5)	5(71.4)	2(28.6)
Myself (woman) alone	163(59.1)	72(44.2)	91(55.8)
Partner and I/husband together	101(36.6)	65(64.4)	36(35.6)
Others	5(1.1)	4(80.0)	1(20.0)

Multivariate Analysis

Factors associated with cervical cancer screening

A Univariable logistic model between the dependent variable having ever screened for cervical cancer and the independent variable showed that being aged 40-49 years (COR 5.0, 95CI: 1.6-16.0, P<0.007), participants who had the highest level of education as primary (COR 2.2, 95CI: 1.2-4.2, P<0.016) and having more than four children (COR 5.7, 95CI: 1.6-20.1, P<0.026). had higher odds of taking up cervical cancer screening. The odds of taking cervical cancer screening increased with age. The women who were students (COR 0.1, 95CI: 0.01, 0.7, P<0.026) had lower odds of taking up cervical cancer screening services.

After adjusting in the multivariable logistic regression, we noted that the women with a primary level of education were 2.4 times as likely to take up cervical cancer screening as compared to the women who had no formal education (Adjusted Odds Ratios [AOR] 2.0, 95CI: 1.2-4.9, P<0.018).

The women who had given birth to at least four children were 5.0 times as likely to taking up cervical cancer screening as compared to the women the women who had not given birth to any child children (AOR 5.0, 95CI: 1.1-23.1, P<0.039) Table 5.

Table 5. Multivariate results

Variable	COR (95% CI)	P-value	AOR (95% CI)	P-value
Age category (completed years)
25-29	1		1
30-39	2.0(1.2, 3.3)	0.010	1.1(0.6, 2.1)	0.811
40-49	5.0(1.6, 16.0)	0.007	2.4(0.6, 9.5)	0.210
Level of education
No formal Education	1		1
Primary	2.2(1.2, 4.2)	0.016	2.4(1.2, 4.9)	0.018
Secondary	0.8(0.4, 1.5)	0.486	1.0(0.5, 2.3)	0.977
Tertiary	2.3(0.9, 5.4)	0.072	2.4(0.7, 7.9)	0.157
Employment status
Employed	1		1
Housewife	0.5(0.2,1.1)	0.084	bb0.5(0.2, 1.4)	0.193
Self-employed	0.4(0.1,1.2)	0.113	0.6(0.2, 1.9)	0.366
Student	0.1(0.01, 0.7)	0.026	0.2(0.02, 1.8)	0.142
Number of children
0	1		1
1-2	1.7(0.5, 5.7)	0.355	1.7(0.5, 6.5)	0.421
3-4	4.0(1.2, 13.7)	0.025	3.8(1.0, 15.4)	0.059
>4	5.7(1.6, 20.1)	0.007	5.0(1.1, 23.1)	0.039
Who usually decides on one’s healthcare
My partner/husband alone	1		1
Myself (woman) alone	3.2(0.6, 16.8)	0.177	1.7(0.3, 9.9)	0.577
Myself and partner/husband together	1.4(0.3, 7.5)	0.706	0.8(0.1, 4.6)	0.766
Others	0.6(0.04, 9.6)	0.736	0.4(0.02, 11.6)	0.623

Qualitative findings

Social demographic characteristics of the qualitative participants

In the qualitative part of the study, we recruited a total of 30 participants. 15 of them had screened for cervical cancer, and the remaining 15 had never screened for cervical cancer. The majority, 50% (15/30), were aged between 30-39. 70% (21/30) were married, 66.7% were Christians, and 63.3% (19/30) of the participants were housewives Table 6

Table 6. Social demographic characteristics of the qualitative participants

Variable	frequency	Percentage
CCS screening status
Screened	15	50.0
Not screened	15	50.0
Age
25-29	10	33.3
30-39	15	50.0
40-49	5	16.7
Marital status
Married	21	70.0
Single/divorced/widow	9	30.0
Religion
Christian	20	66.7
Moslems	10	33.3
Education level
No formal education	4	13.3
Primary	8	26.7
Secondary	13	43.3
Tertiary	5	16.7
Occupation
Housewife	19	63.3
Business	6	20
Salaried	5	16.7

Some of the codes and themes and quotations that merged

The themes that emerged from the qualitative part of the study included individual factors and health system-related factors, and the codes that emerged included perceived health status, lack of information, access to information, unclear/blurry idea of the procedure, and experience with cancer. Some of the themes, codes and quotations that merged are shown in Table 7 Below.

Table 7. Examples of the meanings and themes derived from the thematic framework analysis on attitudes and perceptions regarding cervical cancer screening at Moroto Regional Referral Hospital.

	Themes	Codes	Quotations
Barriers	Individual factors	Perceived health status	“...it needs when you know that you are sick. Because you can’t go to the hospital when you are not sick.to say here is paining, like for me, it’s only this disease of mine that I am suffering from that makes me come to the hospital” (P12 not screened).
	Individual factors	Individual concerns about screening procedures	“…I was worried because she told me you have to undress yourself, so I was fearing also to expose myself…” (P18, not screened).
	Health system-related factors	Accessibility Long waiting time Lack of equipment/stockouts	“…the waiting time is so long because if I have come, I have come specifically for that test, and they give me the information. Now I have already gone through a very long line in OPD and then come and started waiting for a very long line, so you find that on many occasions I miss the test…” (P16, not screened).
Facilitators		Encouragement by health workers	“…what motivated me mostly to do cervical cancer screening was when I got very good information from the nurse…” (P31, screened). “…It is from the health centre that I just know that it is cancer that affects the private part of a woman … this pushed me to go for cervical cancer screening because there was cancer in the services. I had to go for a screen because it could affect the childbearing process. I wanted to have children, so I wanted to make sure I am safe from this cancer” (P21, screened).

Individual factors

Perceived health status

Many participants expressed the belief that visiting the hospital for cervical cancer screening was primarily a response to experiencing specific symptoms or health concerns. They perceived cervical cancer screening as a means to diagnose health issues rather than a preventive measure.

"I heard that when your uterus is paining, you come to the hospital, and they test you and know what disease you are suffering from." (P17, not screened).

"It needs when you know that you are sick. Because you cannot go to the hospital when you are not sick. to say here is paining, like for me, it is only this disease of mine that I am suffering from that makes me come to the hospital." (P12 not screened).

In contrast, some participants recognised the value of cervical cancer screening in assessing their overall health status. Those who had undergone screening expressed a more proactive perspective toward cervical cancer screening.

“It is good to come and test for cervical cancer and know how your body is. And when they give you the drugs, you go and swallow the way they have told you” (P01, screened).

Knowledge of cervical cancer/ screening.

Several participants, particularly those who had not undergone screening, expressed a lack of knowledge about cervical cancer and the screening process

“…I have never heard on how they test for that disease or the way they check…” (P17, not screened).

“I have never screened, but I always hear that they use some machine thing which is metallic. That is what I hear they push in the private part, that is what I hear…” (P13, not screened).

In contrast, some participants, including those who had undergone screening, shared personal experiences and family histories related to cancer. Participant 09, who had been screened, recounted a family history of cancer, stating,

“I remember one time when I was still young, like around 10 years, it happened that my grandfather died of cancer. And it took him long with the pain.

[…] However, he died, but again, my other uncle is also sick of cancer. So, this is one of the things that pushed me to have my self-screen so that I cannot know and treat it before it worsens” (P09, screened).

Participant 09 experience suggests that personal and familial encounters with cancer may have motivated her to seek screening as a preventive measure.

Individual concerns about screening procedures

Individual concerns such as fear and anxiety emerged as prominent emotions associated with cervical cancer screening. Participants who had not been screened expressed apprehension about the screening process, as some women feel uncomfortable and vulnerable during the procedure, hence the fear of being screened. Some participants also expressed dissatisfaction with the procedure

“…I was worried because someone who was screened told me that one has to undress and remain necked before she is screened, so I was also fearing to expose my body to another person who is not my husband…” (P18, not screened).

“I wasn’t satisfied with the procedure which was used for screening because the health worker told me to locate the cervix myself, and I couldn’t reach the cervix; it needed someone else other than me myself…” (P28, screened).

Negative community perceptions and misconceptions about cervical cancer screening raised women's anxiety and reluctance to undergo screening.

“…I was also fearing, as you know, as in the village the way people talk, it scares so that you start fearing and you think screening for screening will make me infertile…” (P31, screened).

Health system-related factors

Knowledge and Awareness of Cervical Cancer

Some participants who had undergone cervical screening highlighted the role of healthcare facilities in raising awareness about cervical cancer. Healthcare providers and facilities can play a crucial role in educating women about cervical cancer and the importance of screening.

“…It is from the health centre that I just know that it's cancer that affects the private part of a woman … this pushed me to go for cervical cancer screening because there was cancer in the services. I had to go for a screen because it could affect the childbearing process. I wanted to have children, so I wanted to make sure I am safe from this cancer” (P21, screened).

Barriers Related to Healthcare Access

Several participants expressed concerns related to healthcare access as a barrier to cervical cancer screening. Participants who had not been screened discussed the long waiting times at healthcare facilities and the lack of screening equipment in the health facilities.

“…the waiting time is so long because if I have come, I have come specifically for that test, and they give me the information. Now I have already gone through a very long line in OPD and then come and started waiting for a very long line, so you find that on many occasions I miss the test…” (P16, not screened).

“…like where I stay, actually I stay in some place near a health centre III where there are no facilities like that equipment’s for testing or screening for cervical cancer screening” (P10, not screened).

This highlights the challenges associated with healthcare facility logistics and the need for efficient screening processes to accommodate women's time constraints and priorities, especially in underserved rural areas.

Influence of Healthcare Providers and Information Dissemination

Several participants emphasised the significant role played by healthcare providers in motivating them to consider cervical cancer screening. This is important for seizing opportunities during healthcare visits to provide information and promote screening.

“…what motivated me mostly to do cervical cancer screening was when I got very good information from the nurse…” (P31, screened).

“Mostly when you have other sicknesses, and you have come to the hospital. They are people who give information about its cervical cancer screening” (P16, not screened).

“…when I came back here to Moroto, whenever I would come like for services like family planning, yes I would always hear from the nurses emphasising.” (P13, screened).

Challenges in Information Dissemination

Some participants, however, faced challenges in receiving information about cervical cancer screening. Participant 06, who had not been screened, described a situation where healthcare providers focused on specific groups, saying,

"That time, they picked only those women, then for us, we asked, but they refused, and they said this season is first for HIV-positive women. So, they took those people, then they talked to those women, then they left us." (P06, not screened).

This indicates potential gaps in equitable information dissemination efforts that need to be addressed to ensure all eligible women receive information about cervical cancer screening.

Community-Based Health Promotion

Many participants mentioned the impact of community-based health promotion efforts on their awareness and motivation to seek cervical cancer screening. Participants noted,

“They used to come in the communities like the nurses and VHTs, and they used to advise women to go for cancer screening in the regional referral hospital…” (P19, not screened).

“…there was a time when it was a radio talk show, and there is a time of public address. But now it has taken several months without us hearing about cervical screening” (P28, screened).

“…the first time I heard about it, there was a sensitisation going on, there was a vehicle moving around sensitising women about cervical cancer and telling women to come to the hospital for cervical cancer test.” (P20, not screened).

Influence of Media and Radio

Media, particularly radio, emerged as another influential source of information for cervical cancer screening. Participant 09, who had undergone screening, mentioned how she obtained information from both radio broadcasts and her visit to the hospital, stating,

“…I got the information from the radio and also from the hospital at the time I came to bring my child to the hospital. I got someone talking about it, and I had the chance to know and get the information” (P09, screened).

Radio talk shows and public address announcements were instrumental in disseminating knowledge about cervical cancer screening.

Prevalence of cervical cancer

In the study, we found that approximately 5 in 10 (47%) of the women had ever screened for cervical cancer. However, the Ministry of Health’s target was to screen 70% of the women aged 25–49 years by 2015 (1), seven years before the survey. However, this finding from Northeastern Uganda is higher than findings from Eastern Uganda (4.8%)(10), Zimbabwe (9%) (11)and Tanzania (22.6%). Most of these studies had small sample sizes and were rural based.

This suggests that there is a significant portion of the population at risk for cervical cancer due to lack of screening. Several factors can contribute to the low prevalence of cervical cancer screening, including limited access to healthcare services, lack of awareness about cervical cancer and screening, cultural barriers, and socioeconomic factors that may hinder women from seeking regular screenings.

Factors associated with cervical cancer screening

Women aged 40-49 years had 5.0 times the odds of taking up cervical cancer screening compared to younger women. This suggests that older women in the 40-49 age group were more likely to undergo screening. Older women may have a higher awareness of the importance of cervical cancer screening, as they might have encountered more health information and discussions throughout their lives. Additionally, healthcare providers may target older age groups for screening due to increased risk with age.

However, age was insignificant in predicting cervical cancer screening when other explanatory variables were controlled in a multivariable logistic regression model. The probable reason for this finding might be that screening behaviours are independent of age, with younger and older women attending the screening on their initiative to remain healthy and health staff advice, respectively. However, this finding is contrary to studies from elsewhere (1,12). As they indicate a significant influence of age on cervical cancer screening.

The study found that women who were students had lower odds of taking up cervical cancer screening services. Students may have limited access to healthcare services or may not prioritise preventive healthcare due to their younger age and relatively better health. This finding aligns with studies that have shown that occupation, particularly being a student, can be a barrier to accessing healthcare services, including cervical cancer screening.

Our study found that women with a primary level of education as their highest level of education had higher odds of taking up cervical cancer screening compared to those with no formal education. Education can significantly impact health literacy and awareness. However, higher levels of education, like secondary and tertiary, were not significant. Our finding is contrary to the previous studies, which suggested that women who had attained higher levels of education were more likely to take up cervical cancer services (13).Education was frequently associated with increased access to health care services and more knowledge regarding health behaviour.

Women with more children may have more interactions with healthcare services due to antenatal and postnatal care, increasing their opportunities for cervical cancer screening. Additionally, women with larger families may have a higher motivation to prioritise preventive healthcare. This finding is consistent with previous research, such as the study by Guillaume et al. (2020) in Kenya. Higher parity (number of children) has been associated with increased odds of cervical cancer screening in several studies (14).

The study identified that many participants believed that visiting the hospital for cervical cancer screening was primarily a response to experiencing specific symptoms or health concerns. They viewed cervical cancer screening as a diagnostic measure to identify health issues rather than a preventive measure. This perception could be due to a lack of awareness about the purpose of cervical cancer screening as a preventive measure. It suggests that many women may not understand the importance of early detection through screening, which is critical for effective treatment. Similar findings have been reported by Ndejjo and others in Uganda found that some women perceived cervical cancer screening as unnecessary unless they had symptoms, indicating a common misunderstanding about the preventive nature of screening (15).

The study identified that several participants, particularly those who had not undergone screening, expressed a lack of knowledge about cervical cancer and the screening process. This lack of knowledge could be a significant barrier to screening. When women are unaware of the purpose and process of cervical cancer screening, they may be less likely to seek it out. The finding of limited knowledge about cervical cancer and screening is consistent with research conducted by Marlow and colleagues in the United Kingdom, which found that some women had misconceptions and lacked knowledge about cervical cancer and screening (16)

In this study, barriers to cervical cancer screening reported were lack of knowledge about cervical cancer and screening, health system challenges, fear of test, outcome, and consequences, and financial constraints.

We found that the lack of knowledge regarding cervical cancer screening by these women was one of the barriers to the uptake of CC in the Karamoja region. We think this could have something to do with the mobile lifestyle exhibited by this population, making it hard to find them with health education services on CC screening. This finding agrees with what Hasahya and others found in their qualitative study beliefs, perceptions, and health-seeking behaviours about cervical cancer in Uganda (17).

Additionally, we also found that the fear of the cervical screening test was also one of the barriers associated with the lack of CC screening among women. The Pap smear and HPV test are used to screen for cervical cancer; however, when an abnormality is found in those two tests, a more invasive colposcopy may be recommended that will allow for a thorough examination of the cervix more closely. This has been associated with some discomfort in women, who reportedly fear screening due to the invasiveness of the test. Additionally, the fear of embarrassment and lack of privacy when the male doctor is the one conducting the test could explain this fear we found in our study. This finding is consistent with what (18) found in their systematic review on the barriers and facilitators to the uptake of cervical cancer screening among women in Uganda, where fear of embarrassment and fear of the screening test were identified as barriers.

In this study, we also found health system challenges to be among the barriers to CC screening. Participants in our qualitative study argued that health system challenges like long waiting hours and lack of test kits to conduct screening were some of the barriers to testing. We think this problem of long waiting hours is connected to the understaffing in the hard-to-reach facilities, which is characterised by the heavy workload. Additionally, the problem of chronic stockout in Ugandan rural health facilities could also explain the lack of test kits for CC screening, which hinders CC screening. This is also in line with the finding of a systematic review by (18), who found that limited resources/ health infrastructure to hinders CC screening for women. To facilitate the uptake of cervical cancer screening, sensitivities should be carried out to increase awareness about the disease and the importance of screening. Also critical is the need to increase access to cervical cancer screening services within communities to address health system challenges such as long waiting times, distances to health facilities and transport costs. To achieve this in a developing country perspective, there is a need to adopt a community outreach model of service delivery where screening services are extended to the community regularly while building capacity at lower health centres. Integration of cervical cancer screening services with others accessed by women, such as antenatal care, family planning or postnatal care, could also increase screening uptake.

The need for more female staff to carry out screening due to the embarrassment felt by some when attended to by male staff was also highlighted. This concern among women has been reported by many previous studies (17,19,20). This gap can be bridged by building the capacity of available female health workers, some of whom may be of lower cadres, such as nurses and midwives, through task shifting to carry out cervical cancer screening of women with support from other staff. It is also important to have a mix of both younger and older staff to cater for all clients. Additionally, the importance of having a well-functioning health system cannot be overstated in this context. In this, the health facilities should have adequate capacity, including a skilled and professional workforce and required supplies and logistics to provide quality screening services to women. These measures should have a positive impact on cervical cancer screening rates.

Strength and limitations

Our study also had some strengths and limitations. This was the first study to explore the prevalence and factors associated with cervical cancers among women of reproductive age living in a nomadic community in Uganda. The study also benefited from both the qualitative and quantitative assessment, which made the study’s findings strong and generalised to a wider community. However, our study also had some limitations; we think it could have suffered from recall limitations, just like most observational studies, where the outcome is assessed through recalls. However, to address this, we made sure that we trained our research assistants to utilise probing questions to enlist recalls.

The study found a low prevalence of cervical cancer screening uptake in the Moroto district. Only 47% of women attending maternal and child health services have undergone screening, which is much lower than the national screening target of 70%. This highlights a significant gap in preventive healthcare, as more than half of the enrolled participants had never taken up screening. This low uptake raises concerns about the potential for late-stage diagnosis and the need for interventions to increase screening rates.

The study highlights specific factors associated with increased odds of taking up cervical cancer screening, including having a primary level of education and having given birth to more than four children. Conversely, being a student was associated with lower odds of screening. These findings underscore the importance of tailoring interventions to specific demographic groups and providing targeted education and outreach efforts.

Various barriers to cervical cancer screening were identified in the study, including limited knowledge about cervical cancer and the screening process, long waiting times at healthcare facilities and the absence of screening equipment in certain areas. These barriers contribute to the low screening uptake and emphasise the need for comprehensive strategies to address these challenges.

Recommendations

Based on our findings, there is a need for the Ministry of Health Uganda, to develop targeted health education and awareness campaigns that aim at increasing knowledge of cervical cancer screening among women with no formal education in the study area.

There is also a need to address barriers related to healthcare access, such as long waiting times and the lack of screening equipment. Healthcare facilities should streamline their processes to reduce waiting times and improve overall efficiency. Additionally, efforts should be made to ensure that screening equipment is available and functional in both urban and rural healthcare facilities. alternatively, there is also a need to consider setting up mobile screening units or outreach programs targeting Karamojong women living in hard-to-reach underserved areas due to their nomadic lifestyle.

There is also a need to identify and target high-risk groups for cervical cancer screening, such as women with a family history of cancer or those with less than four children, since our study found that having less than four children was not associated with cervical cancer screening.

Ethics approval and consent to participate

This study was approved by the Research Ethical Committee (REC) of Busitema University Faculty of Health Sciences after (BUFHS-2023-58. Administrative clearance was sought from the office of the Director of Moroto Regional Referral Hospital. Confidentiality and anonymity were maintained throughout the study and made sure that the information gathered was not accessible to those not directly involved in the study. Participants were also advised not to provide their names and addresses on the questionnaire. Informed consent was sought from all the study participants and participation in the study was voluntary, as the participants were assured about their right to withdraw from the study whenever they liked without any penalty.

Consent for publication

Not Applicable

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author upon reasonable request.

Competing interests

No conflict of interest

Funding

The Research was not funded by any organisation but rather completed with individual funding from the researcher.

Authors' contributions

The primary author contributed to this study by conceptualizing the Research design and drafting the initial manuscript. All the coauthors provided expertise in critically revising the manuscript for intellectual content. The last Author supervised the overall review, provided guidance throughout the manuscript drafting, and critically reviewed and revised the manuscript for important intellectual content. All authors have read and approved the final version of the manuscript.

Acknowledgements

I would like to acknowledge the contribution of the following departments: Department of Community and Public Health, Busitema University, Uganda

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No competing interests reported.

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Prevalence and Determinants of Cervical Cancer Screening Uptake among Women Attending Maternal and Child Health Services in Northeastern Uganda: a Cross-Sectional Study

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