Knowledge, Attitudes and Practices of Young People in Zimbabwe on Cervical Cancer and HPV, Current Screening Methods and Vaccination

Knowledge and awareness of cervical cancer and human papillomavirus (HPV) are consistently low across developing countries, and such lack of knowledge provides a challenge to the implementation of cervical cancer programmes and mass HPV vaccination drives. Meanwhile, in countries like Zimbabwe, recent years have witnessed an increase in risky lifestyle behaviour, including early onset of sexual activity, multiple sexual partners, and age-disparate relationships among the 15- to 24-year age group. The communication strategy of the National Cancer Prevention and Control Strategy for Zimbabwe (2014-2018) focuses on risk factors as primary cancer prevention. In that context, this study aimed to determine the knowledge, attitudes, and practices of young people in Zimbabwe on cervical cancer, screening, HPV, and vaccination so as provide information to cervical cancer stakeholders and programme implementers on how to engage young people in addressing cervical cancer.

This cross-sectional study took place in 6 high schools and 5 universities in 5 provinces in Zimbabwe from August to November 2017. A total of 751 young people (238 high school and 513 university) were recruited through a 3-stage cluster design; female students constituted 68.91 and 60.82% of the participants among high school and university samples, respectively. Their knowledge, attitudes, and practices were assessed using questions based and adapted from the concepts of the Health Belief Model (HBM) and the Cervical Cancer Awareness Measure (Cervical CAM) Toolkit [PDF] from Cancer Research UK (United Kingdom).

Knowledge:
Most young people, 87.47% (656/750), claimed to know what cervical cancer is, with a mean score of 89.98% [95% confidence interval (CI) 73.71.11-96.64] between high school and 86.72% [95% CI 83.48-89.40] among university students. There was no significant difference in mean scores between high school and university students (p=0.676). However, a risk factor knowledge proficiency score of ≥13 out of 26 was achieved in only 13% of the high school respondents and 14% of the university respondents, with a broad range of misconceptions about cervical cancer risk factors in both females and males. Forty-three percent of respondents had heard of cervical cancer screening and prevention, and 47% knew about HPV transmission and prevention.

Attitudes:
The majority of the participants, 94.27% (708/751), acknowledged that young people should be concerned about cervical cancer, with a mean score of 90.30% [95% CI=85.08-92.59] among high school students and 96.20% [95% CI=94.75-97.63] among university students. When the respondents were asked about the perceived risk of them or their girlfriend or wife (in the case of male respondents) developing cervical cancer, 45.34% (258/569) indicated no perceived risk. Some of the reasons they gave were as follows: not being an alcohol drinker or smoker, not using the contraceptive pill, having been circumcised or having a circumcised partner, going for regular medical check-ups, being faithful to one's partner, not being HIV positive, praying, and not being a commercial sex worker.

Practices - information seeking and needs:
A quarter of the young people in this study reported feeling well informed about cervical cancer, with mean scores of 24.43% [95% CI=17.14-32.92] and 26.12% [95% CI 22.32-29.92%] among high school and university students, respectively. Some of the young people who claimed to feel well informed about cervical cancer also wished for more cervical cancer information, with a mean score of 98.09% [95% CI=92.97-99.50] among high school students and 96.30% [95% CI=93.66-97.93%] among university students.

Discussion:
This study revealed that young people in Zimbabwe have an idea about cervical cancer and the seriousness thereof, but they lack adequate knowledge of risk factors and information on where to access cervical cancer services. In fact, over 85% of both high school and university students did not have enough knowledge about cervical cancer or its risk factors. There were no significant differences in knowledge of cervical cancer and its risk factors between high school and university students or rural and urban students; this might indicate lack of cancer education or awareness at a national level.

The researchers observe that Zimbabwe remains both a patriarchal and conservative society, and most men continue to make decisions on the health of women. "This study highlights the ignorance that young people, especially young men, have on cervical cancer and its screening. Men continue to be sidelined in health prevention programmes and this has fueled their passive nature towards health-seeking behaviour, as some responses from young men in this study have shown."

The HBM and socio-ecological model (SEM) hold that increasing knowledge and awareness of a disease, in this case, cervical cancer, may play a role in improving healthcare-seeking behaviour among young people towards cervical cancer prevention services. The researchers urge: "Cervical cancer education and awareness emphasising causes, risk factors, and care-seeking behaviours should be commissioned and strengthened at the community, provincial and national level. Developing a standard cervical cancer primary prevention tool that can be integrated into schools can be a step towards addressing this health inequity. This standard cervical cancer primary prevention tool should be guided by the WHO [World Health Organization]-coordinated strategy towards the prevention of cervical cancer, which sought to include both men and women in cervical cancer initiatives."