Knowledge, Attitudes and Practices of Cervical Cancer Prevention among Zambian Women and Men

"...social interaction is an important factor for the practice of cervical cancer prevention."

In Zambia, cervical cancer screening was started in 2006, and the human papillomavirus vaccine (HPV) was piloted in 2013. Nevertheless, cervical cancer remains the leading cancer. This study focuses on Zambian women as stakeholders, assessing the relationship between their knowledge about cervical cancer, their attitudes and self-reported behaviour towards screening and vaccination, and their immediate support system, including men, other family members, and friends. The approach was informed by evidence from studies elsewhere suggesting that women who believe they have support from their immediate social circles (partner, friends, family) are more likely to be in favour of practicing cervical cancer prevention methods.

The development of the study instrument (a questionnaire) and the selection of study groups were guided by the Social Ecological Model (SEM) and the Theory of Triadic Influence (TTI). The SEM considers intrapersonal, interpersonal, institutional, community, and public policy as levels of influence for health-related behaviours. The TTI is organised in a 3×3 framework, with intrapersonal, interpersonal, and environmental streams of influence, crossed by ultimate, distal, and proximal levels of influence.

A cross-sectional mixed methods study was conducted from February to May 2016. Two separate questionnaires were used to collect data from women (N=300) and men (N=300) residing in Chilenje and Kanyama (2 townships in the capital city, Lusaka). Data collectors knocked on doors or gates to ask parents if they had time and were interested in participating in the research. A leaflet with information on cervical cancer from the local clinic was given to all study respondents after the interview as a form of educating the public. (The effect of handing out these leaflets was not evaluated in this study.)

The majority (63.2%) were not aware of cervical cancer, and knowledge of causes and prevention was very low. Many women had not attended cervical screening (79.3%); furthermore, 93.3% reported not having their daughters vaccinated. When it came to having interest in vaccinating children in the future if given a chance, 82.7% said they would vaccinate their daughters, and 84.0% would vaccinate their sons. Both women and men showed an interest in having the possibility of self-screening, with at total of 80.2%.

Respondents in Kanyama reported that their information on cervical cancer was mostly obtained from healthcare providers (N=93, 66.0%) and television/radio (N=73, 51.8%). In Chilenje, healthcare providers provided most information (N=62, 78.5%), followed by the internet (N=28, 35.4%). A total of 33 respondents stated they had gained information on cervical cancer from their religious group. Thirty of them recalled the different types of information they acquired, which included information on cervical screening (N=15, 50.0%), vaccination (N=7, 23.3%), abstinence from sex (N=7, 23.3%), and practice of safe sex (N=3, 10.0%). The majority of the respondents identified healthcare providers (N=576, 96.2%), the internet (N=256, 42.7%) and television/radio (N=249, 41.6%) as good sources to gain future information on cervical cancer.

There was a strong association between having awareness of cervical cancer and practicing screening (odds ratio (OR)=20.5, 95% confidence interval (CI)=[9.214, 45.516]) and vaccination (OR=5.1, 95% CI=[2.473, 10.423]). Significant associations were found for women who know about screening at government clinics and future vaccination of daughter, women who know about schools that vaccinated and future vaccination of daughter, and men who know about screening in government clinics and vaccination of sons.

There was a strong relationship found between women who have screened and have vaccinated their daughters (OR=9.6, 95% CI=[3.689, 25.114]). In fact, 22.6% of women had vaccinated her daughter if she herself was screened, as opposed to 2.9% if she herself had not screened.

Strong associations were found regarding respondents' awareness of cervical cancer in relation to presumed support and possible support provided by their partner to allow screening attendance. Women who practiced screening were highly likely to also know someone who has screened (OR=18.7, 95% CI=[9.270, 37.554]). Regarding perceived approval of practicing a preventive measure, the researchers found strong associations between perceived approval of screening and actually practicing screening: Women are much more likely to have practiced screening if they enjoy support of their partner, family, or friends. The intention to vaccinate daughters in the future if given a chance is positively related with women's perceived approval from their partners. Intention to vaccinate sons was not significantly associated with support of any kind. For both men (OR=14.2, 95% CI=[4.889, 41.166]) and women (OR=29.0, 95% CI=[10.402, 80.852]), the probability of having daughters vaccinated increases when knowing someone who has vaccinated.

Selected reflections and recommendations based on the findings:

• "There is no denying that general knowledge is fundamental in increasing the practice of prevention methods....Community-based sensitization strategies have proven to be successful in raising awareness, knowledge and prevention practices....Healthcare providers, internet and television/radio were identified as good sources of information and may provide possible targets for conducting interventions aimed at increasing cervical cancer knowledge in Zambia."
• "It can be suggested that there is a relationship between practicing preventive measures and having support especially for women. This implies that Zambian society may be a rather patriarchal society, where men have a big impact in the household. Meaning that for effectiveness of cervical cancer prevention programs, men must be included as a target population."
• "A total of 82.1% of the population professed to be Christians and this increased the chances of having a vaccinated daughter. The more important the respondent regarded their religion proved to be a possible indicator of intending to vaccinate sons. This suggests that churches in Zambia may play a role in improving vaccination practices. One possible explanation is that some Christian denominations are known to actively educate their members on health issues including cervical cancer....Outreach should...be made to churches to ensure the correct information on prevention is disseminated and to encourage church-goers to practice cervical cancer prevention."
• "Knowing people who have practiced cervical cancer prevention methods and support from family play a role in influencing the health behaviors of a society. According to the SEM and TTI, the impact of the people a person may live with should be considered because they may influence whether screening and vaccination will be practiced. Once people are aware of cervical cancer, perhaps by observing the actions of others, practice of prevention methods will increase resulting in a reduction in the spread of this cancer."

"In general, improvements in screening attendance and vaccine acceptance along with behavior change will have a major impact in the prevention of cervical cancer in Zambia."