J Canc Educ DOI 10.1007/s13187-014-0787-7
Cervical Cancer Screening Knowledge and Behavior among Women Attending an Urban HIV Clinic in Western Kenya Joelle I. Rosser & Betty Njoroge & Megan J. Huchko
# Springer Science+Business Media New York 2015
Abstract Cervical cancer is a highly preventable disease that disproportionately affects women in developing countries and women with HIV. As integrated HIV and cervical cancer screening programs in Sub-Saharan Africa mature, we have an opportunity to measure the impact of outreach and education efforts and identify areas for future improvement. We conducted a cross-sectional survey of 106 women enrolled in care at an integrated HIV clinic in the Nyanza Province of Kenya 5 years after the start of a cervical cancer screening program. Female clinic attendees who met clinic criteria for cervical cancer screening were asked to complete an oral questionnaire assessing their cervical cancer knowledge, attitudes, and screening history. Ninety-nine percent of women had heard of screening, 70 % felt at risk, and 84 % had been screened. Increased duration of HIV diagnosis was associated with feeling at risk and with a screening history. Nearly half (48 %) of women said they would not get screened if they had to pay for it.
B. Njoroge Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), P.O. Box 54840-00200, Mbagathi Way, Nairobi, Kenya M. J. Huchko Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco; 50 Beale Street, San Francisco, CA 94143, USA Present Address: J. I. Rosser (*) Department of Internal Medicine, University of Washington, 1959 NE Pacific Street Box 356421, Seattle, WA 98195-6421, USA e-mail: [email protected]
Keywords HIV/AIDS . Cervical cancer screening . Knowledge and attitudes . Behavior . Sub-Saharan Africa
Introduction Cervical cancer, a highly preventable disease with early screening and treatment, remains a leading cause of cancer and cancer-related mortality in Sub-Saharan Africa [1]. Eastern Africa has the highest cervical cancer incidence and mortality in the world with 34.5 cases and 25.3 deaths per 100,000 women [1]. High incidence and mortality rates are attributable to several factors, specifically a lack of programs for early detection and treatment, compounded by high rates of HIV and human papillomavirus (HPV) [2, 3]. Cervical cancer screening rates across Sub-Saharan Africa are estimated to be 0.5–20 %, and in Kenya are estimated to be only 2.4– 4 % [4]. Furthermore, HIV increases a woman’s risk of having persistent HPV infection, high-grade cervical precancerous lesions, and invasive cervical cancer [5]. Additionally, as HIV positive individuals are living longer on antiretroviral (ARV) therapy, they face an increasing burden of comorbid chronic conditions, including cancer [6]. In a recent study in Kenya, 26 % of HIV positive women screened for cervical cancer had abnormal results [7]. To address this synergistic relationship and capitalize on the relatively well-funded and developed infrastructure supporting HIV care and treatment programs, an increasing number of programs are integrating cervical cancer screening into their existing HIV service delivery model [6, 8]. As cancer screening programs emerge within the existing HIV healthcare infrastructure, programs need to evaluate not only their ability to provide high-quality clinical services, but also their effectiveness in increasing patient awareness and knowledge about cervical cancer screening.
J Canc Educ
The World Health Organization (WHO) has suggested metrics for evaluating the success of new cervical cancer screening programs. Outcome measures include ensuring that >80 % of women ages 35–59 years are informed about cervical cancer screening and that >80 % of women ages 35–59 years have been screened at least once during their lifetime [9]. Although the ultimate measure of success is decreasing the incidence of invasive cancer, these intermediate outcomes are important and measureable factors that ensure programs will be able to achieve that goal. Family AIDS Care and Education Services (FACES) provide integrated HIV services in the Nyanza Province of Kenya, the region with the highest HIV prevalence in the country at an estimated 15 % [10]. In 2007, FACES began offering free cervical cancer screening and prevention (CCSP) services using visual inspection with acetic acid (VIA) in their Lumumba Health Center in Kisumu, Kenya and has since provided screening to over 6000 women [8]. Myths about cervical cancer risk factors and treatment options are common, and inadequate knowledge, not feeling at risk, and stigma have been identified as significant barriers to screening uptake in Sub-Saharan Africa [5, 11–13]. Therefore, one key aspect of the program is the community and clinic awareness campaign. All clinic staff underwent general cervical cancer education, with specialized training for health educators, counselors, and clinicians. Cervical cancer information is incorporated into health education talks given at enrollment into HIV care and while waiting for appointments. Personalized counseling is done by nurses and clinical officers during clinic visits, after which eligible women are offered screening. In this study, we assessed knowledge, personal risk perception, stigma, and screening uptake among women enrolled in the FACES clinic 5 years after the start of the CCSP program.
Materials and Methods We conducted a cross-sectional survey of HIV positive women attending an HIV clinic in Kisumu Kenya on their knowledge and attitudes about cervical cancer screening. Women were eligible to participate in they were clinic attendees at Lumumba Health Center in Kisumu, Kenya and met the clinic’s eligibility criteria for cervical cancer screening (nonpregnant women ages 23–64 years). On four separate clinic days over the course of 1 month in April 2013, all eligible women attending the FACES Lumumba Health Center clinic for their regular HIV care were asked at clinic registration if they would be willing to participate in the survey. A total of 106 women were enrolled in the study. This sample size was felt to be adequate to estimate overall clinic screening rates
and cervical cancer knowledge and was powered to detect an 11 % difference in knowledge scores. In a private room, trained interviewers administered the structured survey in English, Kiswahili, or Dholuo, depending on the participant’s language preference, and entered responses directly onto Open Data Kit software (opendatakit.org) on tablet computers. The survey included sections on demographic characteristics, cervical cancer awareness, specific knowledge, perception of risk, stigma, and screening acceptability. Survey questions were based off of previous studies of common misconceptions about cervical cancer in Sub-Saharan Africa and validated questionnaires and were piloted prior to administration [9, 11, 14–16]. The awareness section consisted of five yes/no questions about whether or not participants had ever heard of cervical cancer, screening, Pap smears, visual inspection with acetic acid (VIA), and human papilloma virus (HPV). The knowledge section included 15 true/false questions about facts and common myths about cervical cancer risk factors and prevention. The risk section asked if women felt personally at risk for cervical cancer as well as malaria, breast cancer, and sexually transmitted diseases for comparison. The stigma section adapted a 9-point HIV stigma questionnaire [15] to assess perceived cervical cancer and HIV stigma. Finally, women were asked if they had been previously screened, would pay for screening, and would accept screening by a male provider. For bivariate and multivariate regressions, we used chisquare, t-test, linear, and logistic regression models. Knowledge questions were compiled into a 15-point Knowledge Score which was used in linear regression models. Stigma was dichotomized into ‘having stigma’ if participants responded ‘yes’ to any of the nine stigma statements and ‘not having stigma’ if they responded ‘no’ to all stigma statements; exact logistic regression was used for this analysis because few participants reported any stigma. Multivariate models were created using backwards elimination including variables determined a priori to be potential confounders (age and education) and those that had a p
Cervical Cancer Screening Knowledge and Behavior among Women Attending an Urban HIV Clinic in Western Kenya Joelle I. Rosser & Betty Njoroge & Megan J. Huchko
# Springer Science+Business Media New York 2015
Abstract Cervical cancer is a highly preventable disease that disproportionately affects women in developing countries and women with HIV. As integrated HIV and cervical cancer screening programs in Sub-Saharan Africa mature, we have an opportunity to measure the impact of outreach and education efforts and identify areas for future improvement. We conducted a cross-sectional survey of 106 women enrolled in care at an integrated HIV clinic in the Nyanza Province of Kenya 5 years after the start of a cervical cancer screening program. Female clinic attendees who met clinic criteria for cervical cancer screening were asked to complete an oral questionnaire assessing their cervical cancer knowledge, attitudes, and screening history. Ninety-nine percent of women had heard of screening, 70 % felt at risk, and 84 % had been screened. Increased duration of HIV diagnosis was associated with feeling at risk and with a screening history. Nearly half (48 %) of women said they would not get screened if they had to pay for it.
B. Njoroge Centre for Microbiology Research, Kenya Medical Research Institute (KEMRI), P.O. Box 54840-00200, Mbagathi Way, Nairobi, Kenya M. J. Huchko Department of Obstetrics, Gynecology and Reproductive Sciences, Bixby Center for Global Reproductive Health, University of California, San Francisco; 50 Beale Street, San Francisco, CA 94143, USA Present Address: J. I. Rosser (*) Department of Internal Medicine, University of Washington, 1959 NE Pacific Street Box 356421, Seattle, WA 98195-6421, USA e-mail: [email protected]
Keywords HIV/AIDS . Cervical cancer screening . Knowledge and attitudes . Behavior . Sub-Saharan Africa
Introduction Cervical cancer, a highly preventable disease with early screening and treatment, remains a leading cause of cancer and cancer-related mortality in Sub-Saharan Africa [1]. Eastern Africa has the highest cervical cancer incidence and mortality in the world with 34.5 cases and 25.3 deaths per 100,000 women [1]. High incidence and mortality rates are attributable to several factors, specifically a lack of programs for early detection and treatment, compounded by high rates of HIV and human papillomavirus (HPV) [2, 3]. Cervical cancer screening rates across Sub-Saharan Africa are estimated to be 0.5–20 %, and in Kenya are estimated to be only 2.4– 4 % [4]. Furthermore, HIV increases a woman’s risk of having persistent HPV infection, high-grade cervical precancerous lesions, and invasive cervical cancer [5]. Additionally, as HIV positive individuals are living longer on antiretroviral (ARV) therapy, they face an increasing burden of comorbid chronic conditions, including cancer [6]. In a recent study in Kenya, 26 % of HIV positive women screened for cervical cancer had abnormal results [7]. To address this synergistic relationship and capitalize on the relatively well-funded and developed infrastructure supporting HIV care and treatment programs, an increasing number of programs are integrating cervical cancer screening into their existing HIV service delivery model [6, 8]. As cancer screening programs emerge within the existing HIV healthcare infrastructure, programs need to evaluate not only their ability to provide high-quality clinical services, but also their effectiveness in increasing patient awareness and knowledge about cervical cancer screening.
J Canc Educ
The World Health Organization (WHO) has suggested metrics for evaluating the success of new cervical cancer screening programs. Outcome measures include ensuring that >80 % of women ages 35–59 years are informed about cervical cancer screening and that >80 % of women ages 35–59 years have been screened at least once during their lifetime [9]. Although the ultimate measure of success is decreasing the incidence of invasive cancer, these intermediate outcomes are important and measureable factors that ensure programs will be able to achieve that goal. Family AIDS Care and Education Services (FACES) provide integrated HIV services in the Nyanza Province of Kenya, the region with the highest HIV prevalence in the country at an estimated 15 % [10]. In 2007, FACES began offering free cervical cancer screening and prevention (CCSP) services using visual inspection with acetic acid (VIA) in their Lumumba Health Center in Kisumu, Kenya and has since provided screening to over 6000 women [8]. Myths about cervical cancer risk factors and treatment options are common, and inadequate knowledge, not feeling at risk, and stigma have been identified as significant barriers to screening uptake in Sub-Saharan Africa [5, 11–13]. Therefore, one key aspect of the program is the community and clinic awareness campaign. All clinic staff underwent general cervical cancer education, with specialized training for health educators, counselors, and clinicians. Cervical cancer information is incorporated into health education talks given at enrollment into HIV care and while waiting for appointments. Personalized counseling is done by nurses and clinical officers during clinic visits, after which eligible women are offered screening. In this study, we assessed knowledge, personal risk perception, stigma, and screening uptake among women enrolled in the FACES clinic 5 years after the start of the CCSP program.
Materials and Methods We conducted a cross-sectional survey of HIV positive women attending an HIV clinic in Kisumu Kenya on their knowledge and attitudes about cervical cancer screening. Women were eligible to participate in they were clinic attendees at Lumumba Health Center in Kisumu, Kenya and met the clinic’s eligibility criteria for cervical cancer screening (nonpregnant women ages 23–64 years). On four separate clinic days over the course of 1 month in April 2013, all eligible women attending the FACES Lumumba Health Center clinic for their regular HIV care were asked at clinic registration if they would be willing to participate in the survey. A total of 106 women were enrolled in the study. This sample size was felt to be adequate to estimate overall clinic screening rates
and cervical cancer knowledge and was powered to detect an 11 % difference in knowledge scores. In a private room, trained interviewers administered the structured survey in English, Kiswahili, or Dholuo, depending on the participant’s language preference, and entered responses directly onto Open Data Kit software (opendatakit.org) on tablet computers. The survey included sections on demographic characteristics, cervical cancer awareness, specific knowledge, perception of risk, stigma, and screening acceptability. Survey questions were based off of previous studies of common misconceptions about cervical cancer in Sub-Saharan Africa and validated questionnaires and were piloted prior to administration [9, 11, 14–16]. The awareness section consisted of five yes/no questions about whether or not participants had ever heard of cervical cancer, screening, Pap smears, visual inspection with acetic acid (VIA), and human papilloma virus (HPV). The knowledge section included 15 true/false questions about facts and common myths about cervical cancer risk factors and prevention. The risk section asked if women felt personally at risk for cervical cancer as well as malaria, breast cancer, and sexually transmitted diseases for comparison. The stigma section adapted a 9-point HIV stigma questionnaire [15] to assess perceived cervical cancer and HIV stigma. Finally, women were asked if they had been previously screened, would pay for screening, and would accept screening by a male provider. For bivariate and multivariate regressions, we used chisquare, t-test, linear, and logistic regression models. Knowledge questions were compiled into a 15-point Knowledge Score which was used in linear regression models. Stigma was dichotomized into ‘having stigma’ if participants responded ‘yes’ to any of the nine stigma statements and ‘not having stigma’ if they responded ‘no’ to all stigma statements; exact logistic regression was used for this analysis because few participants reported any stigma. Multivariate models were created using backwards elimination including variables determined a priori to be potential confounders (age and education) and those that had a p
