Beliefs of w om en regarding cervical cancer and screening associated w ith Pap sm ear uptake in Johannesburg

Dr M antw a Chisale M abotjaPublic H ealth M edicine Registrar

Commemorates 9 August 1956 MarchSignificance: Domestic violence, sexual harassment, unequal pay, schooling for all girls, equal access to quality health services

Wathint’abafazi Wathint’imbokodo!

Background • Cervical cancer (cacx): 4th most frequent cause in women globally. ~90% deaths occurring in L-and MICs.

• 2nd common cancer and a leading cause of cancer deaths amongst women in SA

• National cervical screening policy (2000 & 2017)

• Cervical cancer is preventable (HPV vaccine, effective screening)

• Cacx can be prevented through screening -high coverage achieved (WHO, 2014)

• Screening coverage in JHB (DHB, 2017)

Background• Poor coverage factors-healthcare

provider, health system and personal factors (Akinyemiju, 2015)

• Personal factors- health-seeking behaviour

• Theories & models of behaviour: Theory of planned behaviour, Theory of reasoned action, Health belief Model (HBM) (Glanz, 2008)

• Aim: to evaluate the association between women’s beliefs (HBM) and uptake of Pap smears in Johannesburg.

District Health Barometer 2016‐2017

Source: Janz, Nancy K.; Marshall H. Becker (1984). "The Health Belief Model: A Decade Later". Health Education & Behavior

M ethodology

• Cross-sectional analytical study (quantitative)

• Sample size calculation: effect of clustering : 280 participants (80% power, 5% statistical significant level)

• Study population: 280 women age ≥30years, attending primary care facilities for any services in Johannesburg in 2017

• Sampling: Clinic (simple random sample), Participants (systematic sampling

• Interviewer-administered questionnaire-validated measurement scales (CHBM & CSE).

• 5-point likert scale, true or false questions

• Mean scores calculated for HBM constructs

• A logistic regression to determine the associations between beliefs and screening uptake (yes/no) – crude & adjusted OR at 5% significant level (p=0.05)

M ethodologyHBM construct Question

Susceptibility

Max score=15

One’s opinion of chances of getting cacx

Severity

Max score=35

One’s opinion of how serious cacx is & its consequences

Benefits

Max score=45

One’s belief in Pap smear reducing the risk of cacx

Barriers

Max score=70

One’s opinion of the tangible and psychosocial costs of a Pap smear

Cues to action

Max score=15

Strategies to activate Pap smear uptake

Self‐efficacy

Max score=50

Confidence in one’s ability to uptake a Pap smear

Modifying variablesKnowledge, Age, marital status, employment status, highest level of education

Beliefs5‐point likert scale

UptakeEver had a pap smear: 

Yes/No

Socio-dem ographics & know ledgeVariables All women(N=280)

n (%)Ever had a pap smear?(N=177)

n (%)Never had pap smear?(N=103)

n (%)Marital statusSingle/never marriedMarried/have partnerDivorced/widowed

180 (64.3)80 (28.6)12 (7.1)

112 (63.3)51 (28.8)14 (7.9)

68 (66.0)29 (28.2)6 (5.8)

Education levelPrimary school

Secondary schoolTertiary education

32 (11.4)199 (71.1)49 (17.5)

19 (10.7)132 (74.6)26 (14.7)

13 (12.6)67 (65.1)23 (22.3)

Employment statusEmployed full‐timeEmployed part‐timeSelf‐employedUnemployed

133 (47.5)32 (11.4)8 (2.9)

107 (38.2)

96 (54.2)19 (10.7)2 (1.1)

60 (33.9)

37 (35.9)13 (12.6)6 (5.8)

47 (45.6)

AgeMean (SD) 40.4 (9.6) 43.13 (9.6) 35.7 (7.7)

Knowledge scoreMean (SD) 13.4 (2.2) 15.04 (2.19) 13.16 (3.13)

H BM constructs

HBM construct Total(N=280)

Ever had a pap smear? (N=177)

Never had pap smear?(N=103)

Susceptibility scoreMean (SD)                          10.7 (3.7) 10.5 (3.7) 11.1 (3.7)

Severity scoreMean (SD)                          22.6 (7.5) 23 (7.6) 21.8 (7.4)

Benefits scoreMean (SD)                          41.6 (3.3) 41.8 (3.2) 41.3 (3.5)

Barriers scoreMean (SD)                          21.9 (6.5) 19.6 (5.2) 25.9 (6.6)

Cues to actionMean (SD)                          8.1 (3.4) 8.4 (3.4) 7.5 (3.3)

Self‐efficacy scoreMean (SD)                          48.9 (2.7) 49.4 (1.7) 48.2 (3.7)

Factors associated w ith uptakeCharacteristics Crude OR  (95% CI) p‐value Adjusted OR (95% CI) p‐valueMarital statusSingle/never married (ref) Married/living with partner  Divorced/Widowed

1.07 [0.62‐1.84]1.42 [0.52‐3.86]

0.781

Education levelPrimary school (ref)

Secondary schoolTertiary education

1.35 [0.63‐2.89]0.77 [0.31‐1.90]

0.207

Employment statusEmployed full‐time (ref)Employed part‐timeSelf‐employedUnemployed

0.56 [0.25‐1.25]0.13 [0.02‐0.67]0.49 [0.29‐0.84]

0.007*0.61 [0.21‐1.75]0.10 [0.01‐0.95]     0.59 [0.29‐1.18]

0.3600.0450.134

Age 1.68 [1.41‐2.01] <0.001* 1.53 [1.27‐1.84] <0.001*

Knowledge score 5.05 [2.67‐9.52] <0.001* 2.73 [1.25‐5.97] 0.012*

Susceptibility score 0.78 [0.56‐1.09] 0.159 0.71 [0.46‐1.11] 0.132Severity score 1.11 [0.94‐1.30] 0.213 1.31 [1.05‐1.66] 0.017*

Benefits score 1.25 [0.87‐1.79] 0.230 0.99 [0.61‐1.63] 0.981Barriers score 0.41 [0.32‐0.52] <0.001* 0.45 [0.34‐0.59] <0.001*

Health motivation score 1.49 [1.03‐2.15] 0.035* 1.25 [0.78‐2.01] 0.361Self‐efficacy score 2.40 [1.43‐4.17] <0.001* 1.16 [0.59‐2.24] 0.662

Conclusion & Recom m endations

Public health interventions to increase screening uptake:

• Focus on younger women (<40)

• Tailored behaviour change communication strategies that addresses women’s beliefs regarding screening barriers and emphasize the severity of cervical cancer, sensitive to socio-cultural differences and clear misconceptions.

• Further qualitative studies to explore barriers and misconceptions

Acknowledgements

• Co‐authors: Dr Mary Kawonga (Supervisor), Prof. Jonathan Levin• Study participants • Johannesburg health district (Local and Provincial)• Funders: School of Public Health seed grant, Wits Faculty of Health Sciences research grant

• South African Registrars’ Association: Abstract winner (All‐expenses paid for the SAMA 2019 conference)

THANK YOU

m c.Chisale@ gm ail.com

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