knowledge attitudes and practices of cervical cancer screening among women who attend traditional churches in zimbabwe

attend traditional churches in ZimbabweJulia Mutambara, Phillip Mutandwa, Mildred Mahapa, Vonai Chirasha, Sibusiso Nkiwane, Traquilister Shangahaidonhi To appear in: Journal of Cancer Re

attend traditional churches in Zimbabwe

Julia Mutambara, Phillip Mutandwa, Mildred Mahapa, Vonai Chirasha, Sibusiso

Nkiwane, Traquilister Shangahaidonhi

To appear in: Journal of Cancer Research and Practice

Received Date: 5 October 2016

Revised Date: 26 January 2017

Accepted Date: 2 February 2017

Please cite this article as: Mutambara J, Mutandwa P, Mahapa M, Chirasha V, Nkiwane S,

Shangahaidonhi T, Knowledge, attitudes and practices of cervical cancer screening among women who

attend traditional churches in Zimbabwe, Journal of Cancer Research and Practice (2017), doi: 10.1016/

j.jcrpr.2017.02.001

This is a PDF file of an unedited manuscript that has been accepted for publication As a service toour customers we are providing this early version of the manuscript The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain

20 item questionnaire was given to 125 women The results of the study showed that knowledge about factors that caused cervical cancer was relatively high No significant differences were found among the women concerning their feelings towards cervical cancer However, their attitudes towards Pap smear tests were positive in that a large majority of these women (89, 71.2%) acknowledged that they would be worried and seek medical attention if they felt any signs of cancer lesions However, an even larger majority (104, 83.2%) of the women reported not having been screened for cervical cancer The reasons that prevented women from having a Pap smear included: lack of knowledge, belief that cancer was untreatable and religious beliefs that prevented these women from seeking medical care Overall, there is general need to educate women especially from traditional churches to pursue cervical cancer screening in Zimbabwe

Key words: cervical cancer, traditional churches, Zimbabwe, knowledge, attitude, practice

Introduction

Cancer of the cervix (CC) is the second most common cancer affecting women worldwide, and about 86% of CC cases occur in developing countries In fact, these cases actually represent approximately 13% of female cancers overall1 Statistically, CC is one of the leading causes of illness and death amongst the gynaecological cancers worldwide, especially in developing countries 2 The American Cancer Society estimated

that of the over 12.000 cases of invasive cervical cancer diagnosed, approximately 3.000 of the women will die from the disease3 Although CC

is considered one of the most preventable cancers 4, most women who seek help for cancer-related illnesses usually do so when the disease has advanced, and is no longer treatable 5

The situation in Zimbabwe is largely unknown, particularly given the scarcity of epidemiological data However, it is estimated that 2270 women are diagnosed with cancer every year in Zimbabwe, and 1451 die from the disease Cervical cancer is the most frequently occurring cancer among women in Zimbabwe, and the 2nd most frequent cancer among women between 15 and 44 years of age6 There has been an increase in cancer screening centers in Zimbabwe, but further improvements need to be made as the acceptance rate of this service remains low Early detection is quite crucial for a country like Zimbabwe where treatment services such as surgery, chemotherapy and radiotherapy are frequently unavailable for advanced cervical cancer At the few institutions where these services are in place and available, they are usually very expensive and cannot be afforded by many women7

The Human papillomavirus (HPV) is a sexually transmitted infection, recognized as the cause of 99% of all cervical cancers worldwide8 Women are primarily infected with HPV in their teens, 20s, or early 30s6 Therefore, it is recommended that women should be screened three years after their first sexual intercourse The discovery of the human papillomavirus (HPV) as a predominant cause of cervical cancer has necessitated the administration of HPV vaccines as an additional means of cervical cancer prevention 9 The HPV vaccination has the potential to reduce the incidence of cervical cancer worldwide by 70%; the remaining 30% of cancers can be prevented through regular cervical cancer screening 10 Precancerous lesions can be detectable 10 years or more before cancer develops However, it has been noted that many women in developing countries do not obtain screening even when the facility is available About 90% of cervical cancer could be prevented if all women were offered and complied with high quality cytological screening programs 11 Papanicolaou cytological testing (Pap smear) allows cervical lesions to be detected before they become cancerous, thereby effectively reducing the incidence of cervical cancer by 75–90% 9 Following a Pap smear there is a need for a colposcopy procedure, which is the standard follow-up for an abnormal Pap smears12

CC and the resultant health seeking behaviours 17,18.Women`s attitudes towards cervical cancer screening have been found to have an impact on the adoption of cervical cancer screening in many developing countries A study in Thailand found that female sex workers with negative attitudes about Pap smear services were less likely to have ever had a cervical smear taken than those with a positive attitude19.

Most women were found to be unaware of possible prevention of the disease, including screening services for early detection and treatment of precancerous lesions20 Some women affected by CC tend to initially seek treatment from traditional healers and use holy water 17,21 Beliefs concerning the cause of the disease are a crucial determinant of subsequent healthcare-seeking behavior Factors that predict underutilization of cervical cancer screening include older age, lower educational attainment, lower socio-economic status, single marital status, rural residence and negative health and lifestyle characteristics such as infrequent physical activity and not having a regular family doctor 22 Pap smear screening among women has been found to be limited by a lack of knowledge about Pap smears and their importance, feelings of embarrassment and a lack of continuity of care due to a high turnover of health professionals22

Traditional churches in Zimbabwe discourage women from seeking medical attention as they urge them to have faith and receive their healing from God However, the prevalence of cervical cancer among women attending traditional churches in Zimbabwe has not been established The traditional churches (Apostolic Churches) that were the focus of this study have an indigenous origin, with their founders being local Zimbabwean people Correspondingly, they have practices that are quite similar to traditional cultural practices Most of these churches do not allow members to seek medical care These Apostolic churches emphasize faith healing and strict adherence to church beliefs and practices, which undermine the benefits of modern health care For these women, seeking medical care may result in sanctions like confession, shaming, or

a prohibition from wearing church regalia or undergoing rebaptism These churches believe that illness is caused by evil spirits, and that healing

is conducted by prophets and other spiritual leaders23

One hundred twenty-five (125) women participated in this study, who were mainly from the Shona and Ndebele tribes in Zimbabwe The Shona tribe is the largest group of people in Zimbabwe, and includes a population that may speak more than five dialects Their numbers are estimated

to exceed 9 million, represent over 80% of the population and are the most culturally dominant tribe in the country The Ndebele tribe is a minority in the country, and originated from South Africa

Data analysis

Variables were stratified as follows: age (less than 35 years vs 35 years and older), education (13 years of education or more vs less than 13 years of education) and marital status (married or living with a partner vs not married or living with a partner) Descriptive statistics was used in

this study and SAS version 9.2 was used for statistical analysis

Table 2: Knowledge about cervical cancer

What is a Pap smear test ?

Age Tribal group Level of education Marital status

18-29 30-39 40-58 Sh N other Ter Pri Sec Other Mrd N.Mrd W Sp Drv

12 35%

38 52%

12 29%

6 60%

7 58

%

8 36%

38 46%

3 27%

31 46%

12 56%

5 38%

4 24%

4 67%

22 65%

35 48%

30 71%

4 40%

5 42

%

14 64%

42 54%

8 73%

36 54%

10 44%

8 62%

13 76%

2 33%

What is cervical cancer

9 26%

19 26%

13 31%

4 40%

4 33%

4 18%

27 34%

1 9%

20 30%

5 23%

4 31%

4 24%

3 50%

25 74%

54 74%

29 69%

6 60%

8 27%

18 82%

53 66%

10 91%

47 70%

17 67%

9 69%

13 76%

3 50%

Cervical cancer is the second highest cause of cancer death for women in Zimbabwe

27 79%

63 86%

30 71%

6 60%

10 83%

16 73%

66 83%

7 64%

57 85%

19 86%

10 77%

7 41%

6 100%

7 21%

10 14%

12 29%

4 40%

2 17%

6 27%

14 17%

4 36%

10 15%

3 14%

3 23%

10 59%

0 0%

15 44%

33 45%

22 52%

3 30%

9 75%

11 50%

38 48%

6 55%

33 49%

9 41%

5 38%

8 47%

3 50%

19 56%

40 55%

20 48%

7 70%

3 25%

11 50%

42 52%

5 45%

34 51%

13 59%

7 62%

9 53%

3 50%

At what age is a women most likely to have cervical cancer

4 12%

14 19%

10 24%

1 10%

10 83%

3 14%

22 28%

0 0%

15 22%

7 32%

0 0%

1 6%

2 33%

30 88%

59 81%

32 76%

9 90%

2 17%

19 86%

58 72%

11 100%

52 78%

15 68%

13 100

%

16 94%

4 67%

What increases the risk of cervical cancer

25 74%

59 81%

33 79%

9 90%

8 67%

20 91%

66 83%

7 64%

52 78%

18 82%

10 77%

15 88%

6 100

9 26%

14 19%

9 21%

1 10%

4 33%

2 9%

14 17%

4 36%

15 22%

4 18%

3 27%

2 12%

0 0%

Do you think that when cervical cancer is detected early in its course, it can be treated

22 65%

51 70%

27 64%

5 50%

6 50%

14 64%

53 66%

10 91%

48 72%

14 64%

6 46%

10 59%

5 83%

12 35%

22 30%

15 36%

5 50%

6 50%

8 36%

27 34%

1 9%

19 23%

8 36%

7 54%

7 49%

1 17%

Table 2 above shows that there was variation in knowledge among these women The majority (62%) of individuals of ages 18-29 and 38 (52%)

of Shona tribe women had above average knowledge regarding the nature of a Pap smear test However, 42 (54%) women with a secondary level qualification were not aware of the Pap smear test, accompanied by 36 (54%) married women in the study Women of ages 18-29 (79%), 30-39(66%), 40-58(74%), Shona (74%), Ndebele (69%), other tribes (60%), tertiary (27%), 82% with primary level education, 66% with secondary level education and 91% with other qualification presented with a poor understanding of cervical cancer Most of the women presented average

to above average knowledge on recommended periodic screening for cervical cancer

10 (77%) widowed, 15 (88%) separated and 6 (100%) divorced, exhibiting significant knowledge about what enhanced the chances of developing cervical cancer as shown above in Table 2

Further evidence demonstrated relative to above average knowledge regarding how early treatment influences the progression or course of cervical cancer development There were 74%, 61% and 65% of women of ages 18-29, 30-39 and 40-58, respectively, who knew the importance

of early intervention Furthermore, 70%, 64% and 50% of women of the Shona, Ndebele and other tribes had knowledge about how early intervention could positively impact the course of cervical cancer development Six participants with a tertiary education, 64% primary, 66% secondary, 91% other academic qualification, 72% married, 64% not married, 46% widowed, 59% separated and 83% divorced had knowledge about the importance of early intervention

Table 3 Demographic characteristics vs knowledge

Knowledge about cervical demographics

24 (49%)

16 (47%)

40 (55%)

21 (50%)

5 (50%)

5 (41.5%)

11 (50%)

41 (51%)

5 (45%)

37 (55%)

12 (54%)

6 (46%)

7 (41%)

4 (67%)

Moderate

knowledge

6 (14%)

9 (18%)

6 (18%)

11 (15%)

6 (14%)

2 (20%)

2 (16%)

5 (23%)

12 (15%)

3 (27.5%)

12 (18%)

3 (14%)

2 (15%)

3 (18%)

1 (16.5%)

Low

knowledge

13 (31%)

16 (33%)

12 (35%)

22 (30%)

15 (36%)

3 (30%)

5 (41.5%)

6 (27%)

27 (34%)

3 (27.5%)

18 (27%)

7 (32%)

5 (39%)

7 (41%)

1 (16.5%)

Table 4 Attitudes towards cervical cancer screening

Hn Do you feel embarrassed when undergoing a Pap smear

Positive

responses

23 (55%)

25 (51%)

18 (53%)

41 (56%)

19 (45%)

6 (60%)

6 (50%)

10 (45)

47 (59%)

3 (27%)

40 (60%)

12 (55%)

8 (62%)

4 (24%)

2 (33%)

24 (49%)

16 (47%)

32 (44%)

23 (55%)

4 (40%)

6 (50%)

12 (55%)

33 (41%)

8 (73%)

27 (40%)

10 (45%)

5 (38%)

13 (76%)

4 (67%)

22 (45%)

19 (56%)

31 (42%)

26 (62%)

3 (30%)

4 (33)

12 (55)

39 (49%)

5 (45)

34 (51%)

8 (36%)

8 (67%)

6 (35%)

4 (67%)

Negative

responses

23 (55%)

27 (55%)

15 (44%)

42 (58%)

16 (38%)

7 (70%)

8 (67%)

10 (45)

41 (51%)

6 (55%)

33 (49%)

14 (64%)

4 (33%)

11 (65%)

2 (33%)

28 (57%)

26 (76%)

56 (77%)

27 (64%)

5 (50%)

7 (58%)

17 (77%)

57 (71%)

7 (64%)

42 (63%)

18 (82%)

10 (78%)

13 (76%)

5 (83%

Negative

responses

14 (33%)

15 (43%)

8 (24%)

17 (23%)

15 (36%)

5 (50%)

5 (42%)

5 (23%)

23 (29%)

4 (36%)

25 (27%)

4 (18%)

3 (22%)

4 (24%)

1 (17%)

35 (71%)

25 (74%)

55 (75%)

25 (60%)

9 (90%)

11 (92%)

12 (55%)

59 (74%)

7 (64%)

47 (70%)

15 (68%)

8 (62%)

14 (82%)

5 (83%)

Negative

responses

13 (31%)

14 (29%)

9 (26%)

18 (25%)

17 (40%)

1 (10%)

1 (8%)

10 (45%)

21 (26%)

4 (36%)

20 (30%)

7 (32%)

5 (38)

3 (18%)

1 (17%)

28 (57%)

14 (41%)

36 (49%)

26 (62%)

6 (60%)

7 (58%)

10 (45%)

44 (55%)

7 (64%)

39 (61%)

13 (59%)

3 (23%)

11 (65%)

2 (33%)

Negative

responses

16 (38%)

21 (43%)

20 (59%)

37 (51%)

16 (38%)

4 (40%)

5 (42%)

12 (55%)

36 (45%)

4 (36%)

28 (39%)

9 (41%)

10 (77%)

6 (35%)

4 (67%)

(n=125)

There were no significant differences between and within different groups of women in expressing feeling towards having a Pap smear as highlighted by the ANOVA tests The P-value on age was 996; tribal group experiences 371, level of education 182 and marital status 081 Furthermore, the majority reported varied experiences when the health care provider performing the Pap smear was male or female Thus, women with positive attitudes towards Pap smear tests were those who did not discriminate undergoing the tests based on the gender of the health care provider Hence, the majority of women who were affected by the gender of the health care provider were those between ages 30-39

of both tribes Moreover, most women (51.25%) with a secondary education were significantly affected by the gender of the health care provider

in deciding whether or not they would have a Pap smear, which was further underscored by the fact that the majority (45.6%) of these women were married No significant differences between and within groups in the experience were identified as shown by the following P-values: age = 699, tribal group = 080, level of education = 834 and marital status = 197

The majority of women of all ages agreed that the Pap smear test was not very expensive; this understanding was shared by all women in different tribes, educational levels and marital statuses Therefore, of the 125 women participants, 104 (83.2%) had never undergone a Pap smear However, the attitude towards Pap smear tests was positive, with the majority 89 (71.2%) of women acknowledging that they would be worried and seek medical attention if they felt any signs of cancerous lesions However, most of the women in TCZ shared the same perspective,

as no significant difference between and within these groups of individuals were noted with the P-value of age = 117, tribal group = 078, level

of education = 117 and marital status = 711 above the level of significance Further evidence illustrated that religion shaped the decisions that