Baseline knowledge on risk factors, symptoms and intended behaviour of women and men towards screening and treatment of cervical cancer in rural Uganda: A cross-sectional study

Baseline knowledge on risk factors, symptoms and intended behaviour of women and men towards screening and treatment of cervical cancer in rural Uganda: A cross-sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Baseline knowledge on risk factors, symptoms and intended behaviour of women and men towards screening and treatment of cervical cancer in rural Uganda: A cross-sectional study Carolyn Nakisige, Marlieke Fouw, Miriam Nakalembe, Orem Jackson, and 6 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3849445/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Apr, 2024 Read the published version in BMC Cancer → Version 1 posted 8 You are reading this latest preprint version Abstract Background Knowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behaviour of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms. Methods This cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30–49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behaviour and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men. Results A total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men. Lack of decision making by women was associated with low knowledge of risk factors (X 2 = 14.542; p = 0.01), low education (X 2 = 36.05, p < 0.01) and older age (x 2 = 17.33, p < 0.01). Men had better help seeking behaviour than women (X 2 = 64.96, p < 0.01, OR = 0.39, 95% CI: 0.31 - 0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X 2 = 27.28, p < 0.01, OR = 0.52, CI (0.40 - 0.67). Conclusion The baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behaviour towards screening was also positive but screening uptake was very low. This study suggests developing messages on multiple interventions to promote screening behaviour in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly. Risk factors symptoms intended behaviour cervical cancer screening Background Worldwide, cervical cancer is the fourth most common cancer among women and mainly affects women in low- and middle-income countries. Screening and treatment of pre-cancerous lesions are key to prevent cervical cancer effectively. The World Health Organization’s (WHO) elimination strategy recommends high risk Human Papilloma Virus (hrHPV) self-collected testing as primary screening because it is very sensitive, objective and highly accepted among women. It is a promising method to increase screening uptake [ 1 ]. Uganda has one of the highest incidence and mortality rates due to cervical cancer. This has been attributed to low screening uptake which in turn is influenced by lack of knowledge about cervical cancer coupled with a poorly functioning health infrastructure [ 2 , 3 ] and high prevalence of risk factors among others [ 4 ]. The incidence of cervical cancer rose at a rate of 1.8% per year over a period of 20 years between 1991 to 2010 [5 ]. Incidence of cervical cancer was projected to increase by 35.3%, and Age Standardized Incidence Rates projected to increase up to 66.1 per 100 000 women by the year 2030, [ 6 ] if no intervention is put in place. Being a reproductive cancer, generally caused by infection with Human Papilloma Virus (HPV), prevention of cervical cancer is largely dependent on male support and involvement. Men play an important role in HPV transmission as HPV DNA has been detected in their genitalia ranging from 55.3–76.6% among HIV positive men and 38.6–47.6% among HIV negative men [ 7 ]. Furthermore, men are often decision makers in rural settings in Uganda and will often decide whether their women can be screened [ 8 ] and treated for pre-cancerous lesions [ 9 ]. Limited knowledge among men about the risk factors and causes of cervical cancer can limit uptake of screening. Good knowledge among men would enable them to embrace the prevention programmes and also to support and encourage the women to go for screening and to seek medical help on acquisition of symptoms of cervical cancer.[ 10 ] Poor recognition of cancer symptoms by both patients and primary healthcare professionals may contribute to the advanced stage at diagnosis and poor survival of cervical cancer patients in Uganda [ 11 , 12 ]. Ugandan women with vaginal symptoms often first attribute their symptoms to gynaecological infections such as candidiasis and sexually transmitted infections. Only if symptoms persist despite medications, then women sometimes attribute their symptoms to cancer [ 13 ]. The presence of symptoms usually implies advanced disease. Early recognition will aid in early diagnosis before advanced cancer is developed. Prevention of the cancer is key in the fight towards elimination. Knowledge of the cause, risk factors and symptoms of cervical cancer are determinants of preventive behaviour such as screening and seeking medical help for early detection, which translates into reduction in the incidence, morbidity and mortality due to cervical cancer [ 14 ]. Information is needed on how best to design preventive interventions in the community. The Prevention and Screening Innovation Project Towards Elimination of Cervical cancer (PRESCRIP-TEC) [ 15 ] was initiated to evaluate the feasibility of the WHO strategy in resource-constrained circumstances and targets women living in rural areas in Uganda, Bangladesh and India. As part of the PRESCRIP-TEC project, the objective of this study was to gain understanding of the baseline cervical cancer knowledge and intended behaviour towards screening and treatment among women and men/decision makers in a rural community setting in Uganda, to enhance the specific communication strategy aimed at increasing uptake for cervical cancer screening and seeking help for early detection. Methods Study Setting The study was conducted from March 2022 to July 2022 in the districts of Kakumiro and Kagadi in Western Uganda. In both districts, 3 sub-counties were targeted in Kakumiro district and in Kagadi district. Each of the sub-counties is served by at least one health centre III. Health centre III is the lowest level facility in the health structure where cervical cancer screening and treatment is carried out as per the national guidelines Strategic plan 2010–2014 [ 16 ]. Study population and Eligibility criteria Women were included if they were aged 30–49 years old, able to participate in a screen and treat programme, able to give informed consent for participation in the study and had the skills to respond to questions. The age limits align with the Uganda national cervical cancer screening guidelines. Women were excluded if they were pregnant, had history of hysterectomy, had prior treatment for cervical disease or had signs and symptoms of cervical cancer. Men (husbands/decision makers of the women from the same households) aged 20–70 years with skills to respond to questions and or engage in an interview were included. Men who refused or were unable to provide informed consent were excluded. Study design and Sampling This was a cross-sectional study and sampling was non-randomised. The sub-counties in Kakumiro district were purposively selected for having no cervical cancer screening services available while those in Kagadi district were randomly selected because screening was available. The sample size was arrived at by calculating differences in awareness scores of at least 10% between women and men, applying a two-sided two-sample test with alpha = 0.05, a standard deviation of 0.2 and allowing for a 15% non-response rate. We targeted 400 women and their male counterparts from each of the districts. Data collection The Village Health Teams (VHTs) provide the first level of primary health care in Uganda. The teams consist of community volunteers, both women and men, chosen by community members to provide healthcare services to their communities and are regarded as Health Centre I (HC I) [ 17, 18,19]. Each VHT serves about 1000 people or 25 households in a village [ 20 , 21 , 22 ], and they provide linkage between the community and the HCs [ 18 , 17 , 21 ]. In addition to other functions, the VHTs are to raise awareness and mobilise community members to participate in cervical cancer prevention activities [ 23 ]. For each sub-county prior to data collection, 12 VHTs were trained for a period of 5 days by the principal investigator (CN). The training included the basics of cervical cancer, the cause, risk factors, symptoms, signs and prevention of cervical cancer. VHTs were also trained on the research protocol, Good Clinical Practice, the consenting process and the questionnaire. VHTs were selected by the Head VHT based on literacy levels. They collected data from one village at a time until; all homesteads were visited. All interviews were conducted in the homes of the women and her husbands/decision makers after establishing eligibility and informed consent obtained. Data was initially collected on paper questionnaires and later double entered into the REsearch Data Capturing system (REDcap) by data entry clerks. Data was checked for completeness and as part of quality control, the research assistants revisited the households when data was not complete and or aspects of the data were not clear. Instruments In order to measure cervical cancer awareness and intended behaviour, the adapted version of the African Women Awareness of CANcer (AWACAN) instrument was administered. The AWACAN tool has shown to be reliable and valid for use in Sub-Saharan Africa. It is a 41-item questionnaire that measures women’s awareness of cervical cancer. The tool measures awareness in the following domains: risk factors, symptoms, lay beliefs, confidence in appraisal, health-seeking behaviours, and barriers to health care and has socio-demographic questions [ 24 ]. The questionnaire was validated with questions on knowledge of risk factors and symptoms of cervical cancer, help-seeking behaviour, confidence skills and behaviour regarding symptoms and barriers to seeking help. Prior to data collection, the instrument was pilot tested and forward and backward translation to Runyoro-Kitara language done. Based on the pilot, separate versions for women and their husbands or household decision makers were prepared. The AWACAN questionnaire assessed 11 risk factors and 12 symptoms of cervical cancer. Knowledge of risk factors was only assessed on respondents who had ever heard of cervical cancer while symptoms were assessed on the total sample included as per the AWACAN tool. To assess intended behaviour, we measured health-seeking behaviour, confidence in identifying signs and symptoms and barriers to seeking medical help. Health seeking behaviour was assessed using 6 questions. Confidence in identifying signs and symptoms of cervical cancer was measured using 3 questions. Barriers to seeking medical help was measured using 12 questions. Data Analysis The collected data was coded, entered and analysed using Statistical Package for Social Sciences version 26. Univariate analysis was done to obtain the descriptive statistics (demographic characteristics) of the participants. Bivariate analysis and comparison of all AWACAN question responses between female respondents and men was done. Measures on knowledge scores included median and interquartile ranges. Knowledge scores were categorised into binary outcome as less knowledgeable below the median scores and highly knowledgeable with median and above the median scores. Bivariate analysis using Chi square tests were conducted to determine associations between the binary knowledge scores on risk factors and symptoms of cervical cancer with socio-demographic correlates. Multivariate logistic regression models were applied on categorical variables to determine the magnitude of association between knowledge of risk factors and symptoms of cervical cancer with the demographic factors. We also checked for the assumptions. Statistical significance was set at p-value < 0.05. Odds ratios and accompanying 95% confidence intervals stated. Results Socio-demographic characteristics of the participants A total of 1,416 participants, 724 (51.1%) women and 692 (48.9%) men were interviewed. More than half of them were less than 40 years old with a mean age of 37 years for the female respondents and 38 years for the male respondents. See Table 1 . Table 1 Socio demographic characteristics of participants Variable Category Female N = 724 Male N = 692 Age (years) Mean (SD) 37.39 (5.69) 37.88 (7.13) n (%) n (%) Education No education 69 [16.2] 71 [16.1] Primary School 325 [76.5] 335 [75.7] Secondary school 31 [7.3] 33 [7.5] Tertiary 0 3 [0.7] Marital status Married 312 [63.3] 272 [ 62.0] Single 48 [9.8] 56 [ 12.8] Widowed 17 [3.4] 13 [ 3.0] Cohabiting 107 [21.7] 90 [ 20.5] Divorced 9 [1.8] 8 [ 1.7] Ever heard of cervical cancer? Yes 510 [ 71.0] 459 [67.2] No 208 [ 29.0] 224 [ 32.8] Has a health worker ever tested you for cervical cancer? Yes 61 [ 8.8] NA No 633 [91.0] NA Refused 1 [ 0.1] NA Don’t know 1 [0.1] NA Who makes decisions concerning your health? Myself 229 [31.7] NA My partner 254 [ 35.2] NA Myself and partner jointly 226 [31.8] NA Someone else in the household 11 [ 1.5] NA Myself and someone else jointly 2 [ 0.3] NA Knowledge on risk factors of cervical cancer Knowledge of risk factors for cervical cancer was assessed in 510 women and 459 men. These are participants who responded positively to ever having heard of cervical cancer. HPV infection being a risk factor for cervical cancer was known by 74.5% of the women and 72.2% of the men. Having many sexual partners was recognised by 82.9% women and 78.8% men, while smoking was recognised by only 55.6% of the women and 54.5% of the men. Giving birth to more than 3 children was the only risk factor with significant difference in knowledge between men and women; the women were more knowledgeable than the men. See details in supplementary material Table 1. Knowledge on symptoms of cervical cancer Knowledge on symptoms and/or signs of cervical cancer was assessed in 724 women and 692 men. A persistent smelly vaginal discharge was the commonest recognised symptom of cervical cancer while persistent diarrhoea was the least recognised symptom. The women were 8 times more likely to recognise lower back pain as a symptom of cervical cancer than the men. See details in supplementary material Table 2. K nowledge scores on risk factors and symptoms A total of 510 women and 459 men were assessed on 11 risk factors for cervical cancer. The median number of risk factors recognised was 8 (IQR 6–10) for both women and men; 60% of the women and 57.4% of the men could recognise 8–11 risk factors, 22 (4.3%) of the women and 33 (7.2%) of the men couldn’t recognise a single risk factor for cervical cancer. Of the 724 women and 692 men assessed on recognition of symptoms, 64.6% and 60.5% respectively could recognise 8–12 symptoms out of the 12 symptoms, while 67 (9.3%) women and 71(10.3%) men couldn’t identify a single symptom of cervical cancer. Table 2 . Table 2 Knowledge scores of cervical cancer risk factors and symptoms. Knowledge scores Females Males Variables Risk factors = 510 Symptoms n = 724 Risk factors n = 459 Symptoms n = 692 Median score [ 8 ], IQR [6.0–10.0] 65 ( 12.8%) 87 (12.0%) 43 (9.4%) 64 (9.2%) Below median score 202 (39.6%) 256 (35.4%) 196 (42.7%) 273 (39.5%) Above median score 243 (47.6%) 381 (52.6%) 220 (47.9%) 355 (51.3%) Key: Interquartile range (IQR). Association between knowledge of risk factors and symptoms of cervical cancer with social demographic characteristics. Age, Education attainment and marital status were all not associated with knowledge of risk factors and symptoms for cervical cancer for both the women and the men. See supplementary information Tables 3 and 4 . Decision making in comparison with other factors Women whose husbands/decision makers made decisions for them with regard to issues of health were 15 times likely to be less knowledgeable about risk factors of cervical cancer compared to women who made their own decisions or in partnership with their husbands. They were also more likely to be older and less or not educated. Table 3 . Table 3 Decision making in comparison with other factors. Variable Category Myself n (%) Partner n(%) Myself and Partner n (%) X 2 P Value Risk factors Low knowledge 52 (32.9) 74 (45.1) 66 (37.7) 14.54 0.001 High knowledge 108 (67.18) 90 (54.9) 109 (62.3) Symptoms Low knowledge 48 (27.9) 52 (29.4) 64 (33.0) 2.11 0.72 High knowledge 124 (72.1) 125 (70.6) 130 (67.0) Age 30–39 61 (79.2) 59 (65.6) 61 (55.5) 17.33 0.002 40–49 16 (20.8) 31 (34.4) 49 (44.5) Education CP 20 (12.5) 12 (7.3) 25 (14.3) 36.05 0.003 CS 10 (6.3) 4 (2.4) 6 (3.4) LP 42 (26.3) 56 (34.1) 60 (34.3) None 5 (3.1) 18 (11.0) 20 (11.4) Key: CP – Completed Primary school, CS – Completed secondary school, LP – Didn’t complete primary school, None – No formal education, X 2 - Chi square. Knowledge of risk factors, symptoms and intended behaviour towards cervical cancer among women and men. There was no significant difference between the women and men in their knowledge of risk factors and symptoms. However, men had better health seeking behaviour than women, and more confidence, skills and behaviour towards signs and symptoms of cervical cancer. See details in supplementary table 5. Barriers to seeking medical help were found in 316 (43.9%) of the women and 314 (45.4%) men but there was no difference between the two groups, neither did barriers affect them significantly. See details in Table 4 and supplementary table 5. Table 4 Knowledge of risk factors, symptoms of cervical cancer and intended behaviour among men and women Variable Category Females n [%] Males n [%] X 2 P-value OR 95% CI Knowledge of cervical cancer risk factors n = 969 Low score 154 [30.2] 196 [42.7] 0.03 0.86 0.98 0.74–1.292 High score 356 [69.8] 263 [ 57.3] Knowledge of cervical cancer symptoms n = 1416 Low score 256 [35. 4] 273 [ 39.5 ] 2.53 0.11 1.19 0.96–1.48 High score 468 [64.6] 419 [60.5] Help seeking behaviour n = 1409 No 313 [43.6] 161 [23.30] 64.96 < 0.001 0.393 0.312–0.495 Yes 405 [56.4] 530 [76.7] Confidence skills and behaviour to a sign or symptom n = 1407 No 221 [30.9] 130 [18.8] 27.28 < 0.001 0.52 0.40–0.67 Yes 495 [69.1] 561 [81.2] Barrier to seeking help n = 1411 No 404 [56.1] 377 [54.6] 0.34 0.56 1.07 0.86–1.31 Yes 316 [43.9] 314 [45.4] Key: Odd’s ratio - OR; Confidence Interval - CI Discussion This community-based study provides information on baseline knowledge of risk factors and symptoms of cervical cancer and intended behaviour towards screening and treatment for cervical cancer of women and men living in rural Uganda. We found that knowledge of risk factors and symptoms was high in the majority of participants, with no difference between the women and the men. We also found that despite this high knowledge, intended behaviour to screen and the apparent insignificant barriers, the screening uptake was very low necessitating further investigation into this discrepancy. Results from this study can inform specific target group communication and other implementation strategies on cervical cancer prevention aimed at increasing uptake for screening and early detection. Knowledge on cervical cancer In our study, there was no association between the demographic factors and knowledge of risk factors and symptoms, probably because the population was generally uniform with no significant differences with regard to their demographic characteristics and knowledge of cervical cancer. This is unlike other studies where low knowledge of risk factors was associated with not being married [ 25 ] and low education [ 26 ]. In another study the level of education was associated with high knowledge for risk factors while older age was associated with symptom awareness [ 27 ]. More than 60% of both women and men were able to recognize at least 8 out of 11 and 12 risk factors and symptoms respectively of cervical cancer, making it a knowledgeable population with no difference between the women and men. Knowledge of risk factors promotes preventative behaviour like screening and vaccination against HPV while knowledge of the symptoms promotes health seeking behaviour and thus early detection. It is known that knowledge of cervical cancer is a determinant of screening uptake [ 3 , 28 ], but the knowledge of the participants in this study was not commensurate with the level of uptake. This reciprocates with the review by Lott et al., where they analysed interventions to increase uptake of cervical screening in Sub-Saharan Africa (SSA) and found that educational interventions were the most common type of intervention used to increase uptake of cervical screening in SSA but also the least effective [ 29 ]. However, a few studies that utilised peer health educators and community health educators as part of the implementation strategy were an exception emphasising the role of social ties, using educators that were already known to the study participants [ 30 , 31 ]. This means that education as an intervention may not yield much. But if delivered by peers and community health educators it may influence screening uptake. In addition, education needs to be combined with actual availability of the appropriate services. This was noted in our study areas where knowledge of the respondents was high in both districts, but uptake was 6.6% in the district with no services and 11.1% in the district with services. This difference was not significant but notably more women had been screened in the latter and the few women who had been screened in the former could have sourced it in another district. Intended behaviour The Integrated Behavioural model (IBM) is hinged on the fact that the most important determinant of behaviour is intention to perform that behaviour, and that intention is influenced by attitudes, perceived norms and personal agency [ 32 ]. In our study the high knowledge and good intended behaviour did not translate into screening behaviour. Lott et al observed very high willingness to screen but that intent to screen did not always translate into uptake of cervical screening [ 29 ]. Similarly, Ndikom et al., described an increase from 75.8–91% in willingness to screen, yet no change in actual screening was observed [ 33 ]. Therefore, intended behaviour alone does not guarantee behaviour change. More research is required to find out what more needs to be done to allow this intention to translate into actual screening uptake. Decision making We found that the women who took no part and depended on their husbands to make decisions concerning their health were least knowledgeable about risk factors of cervical cancer, followed by those who decided in partnership with their husbands, while the women who made their own decisions were most knowledgeable of all the women. In addition, women whose husbands made decisions for them were least educated or mostly with no formal education at all and were also older putting them at most risk for cervical cancer [ 34 ]. The trend was similar in those who made decisions in partnership with their husbands and were next at risk. The women who made their own decisions were more knowledgeable on risk factors, most educated and younger than the two groups. This is in agreement with another study on women’s healthcare decision making and cervical cancer screening uptake done in 4 countries in SSA, in which showed that women who are able to make autonomous healthcare decisions were most likely to uptake cervical cancer screening followed by those who decided in partnership with their husbands and least of all were those whose decisions were solely made by their husbands. [ 35]. Ndikom et al., [ 33 ] in their study in Nigeria reported lack of decision-making ability as a barrier to screening. Formal education and training were found to be key to raising women’s confidence as was reported in the Wagner study [ 36 ]. Building confidence in those women was demonstrated to have a multiplying effect in getting women to screen. In their pilot, women who had screened were trained as advocates for cervical cancer screening and this resulted in increased numbers of women taking up screening. [ 36 ]. Therefore, policy interventions should focus on empowering women to make autonomous decisions or in partnership with their husbands with regard to issues concerning health. Male involvement In this study, 60% of the women had decisions made for them by the men or in partnership with them. Men play a role in the transmission of the HPV infection. This makes men a critical target for impactful communication and other interventions aimed at increasing screening uptake. Men and their involvement in the control of cervical cancer are key players in the elimination of cervical cancer [ 9 , 10 , 11 ]. In this study men had significant better health seeking behaviour compared to the women. This could be attributed to the fact that health seeking is associated with certain expenses such as transport and medical costs. Since men generally are the bread earners and decision makers [ 9 ], they usually control the budget to spend rather than the women. If men are better educated about risk factors and symptoms of cervical cancer, they are more willing to support their wives in providing support for cervical cancer screening. This is supported in various studies where men were willing to support their wives to seek help in case of symptoms and also willing to support them for screening [ 11 , 37 , 38 , 39 ]. Other studies have tried integrating male services into cervical cancer screening programs with some positive results [ 29 ]. This could be an area for more research. Additionally, men felt more confident at recognizing a symptom of cervical cancer than the women. This could be attributed to a cultural norm where the men are the decision makers and thus expected to know more than the women, or a possible socially desirable response. Increasing community knowledge of cervical cancer symptoms among others and tackling perceived barriers to health seeking, could lead to prompt and appropriate symptom appraisal and help seeking and contribute to improved cancer outcomes. Given more education on cervical cancer and the role they can play in preventing it, combined with targeted communication messages and active involvement, men would significantly impact on screening uptake which would in turn contribute towards elimination of cervical cancer. Barriers Transport as a barrier to seeking medical help did not feature significantly but more than 40% of the women reported it was a problem. Therefore economic empowerment of the women so that they do not depend on the men, could possibly influence them to taking up screening for cervical cancer since lack of transport has been cited to be a barrier to screening in several studies [ 28 ]. However, economic incentives to women increased uptake very minimally of less than 20% [ 37 , 40 ]. This intervention may not work and let alone be sustainable. It may need to be coupled with other interventions. Barriers to seeking medical help were surprisingly lower in our study compared to other studies probably because the respondents were aware of most of the risks and symptoms of cervical cancer and the advantage of seeking medical help. More than half of the participants both women and men would seek medical help once there are symptoms. This is in contrast with the study by Birhanu et al., [ 41 ] where cervical cancer was associated with a lot of stigmas. It was thought that frequent sex with multiple partners was the cause. Afraid of stigma, women shied away from seeking help. Issues like long waiting time, fear of the diagnosis, lack of transport and others did not feature as obstacles to seeking medical help in more than half of the participants in our study contrary to what was previously reported [ 28 ]. Service availability In the review by Lott et. al, studies that utilised innovative service delivery approaches focusing on availability, accessibility and appropriateness of screening services for women resulted in the greatest increases in screening uptake. [ 29 ]. At the time of this study, there were no screening services in the entire district which would explain the low uptake confirming availability of services to be crucial in enabling behaviour to screen. [ 33 , 42 ] In another study, accessibility was addressed by changing location of the screening services from health facilities and bringing them to the doorsteps of the women avoiding transport as a barrier. This led to tremendous increase in screening uptake which was not possible when women were referred to hospital for screening [ 37 ]. Community based service delivery addressed the issue of accessibility. We recommend this approach as it has been proved to yield increase in screening uptake. Uptake was even higher when the test was switched from Visual Inspection with Acetic acid (VIA) to self-collection. In Uganda and other places, self-collection registered uptake higher than 90% and the women reported very good attitude towards this type of screening. Coupled by integration into existing services and having community health workers drive the project was acceptable by the women because of working with their own well known community healthcare workers and feeling in charge of their own health given the technique of self-collection in the comfort and privacy of their homes. This made the service delivery women friendly/appropriate and resulted into screening uptake of more than 90% [ 43 ]. We therefore recommend this proven women friendly approach of self-collection in their homes by community health workers and anticipate an increase in the screening uptake in this community. Strengths and limitations This study was conducted by trained local VHTs who spoke the local language and knew the homes of all the residents ensuring coverage of the area. The willingness of men who are decision makers to be involved in the prevention and early detection of cervical cancer for their wives is an advantage for the next phase of intervention of this study. Another advantage was the fact that the study was conducted in a very rural place which may be similar and may be representative of many of the other parts of the country in Uganda. The other strength of this study is that we investigated the intended behaviour of the men which greatly informs policy on intervention. The sample size of 1,416 participants was less than was calculated due to the fact that the study was conducted during the rainy season, making it sometimes difficult to find potential participants. This however has enough power to draw conclusions from the results generated. Among the limitations, social desirability cannot be ruled out given that the questionnaires were administered face to face. This was minimised by the fact that the VHTs were adequately trained and emphasised to the participants that their responses were going to be kept anonymous with confidentiality and privacy observed. There was a degree of selection bias given that the sub-districts in the intervention areas were selected by community and political leaders on the basis that there were no screening services in those areas. However we think that results would have been similar if another area had been selected for the study within the same region. This was minimised by ensuring that all villages and all households with eligible participants were included in the study with the help of the local VHTs. Another disadvantage of this study is the lack of a standardized knowledge assessment questionnaire which limits the comparability of the findings across studies carried out in the region, but the findings of which can be used to develop target specific messages on cervical cancer prevention and early detection. Conclusion Knowledge of risk factors and symptoms and signs of cervical cancer in the majority of participants was high in both women and men with no significant difference between the two groups. The intended behaviour for both women and men towards screening or early diagnosis and early detection was generally positive. Barriers to seeking medical help didn’t significantly affect the population to go for screening and yet despite all the above factors, screening uptake was very low. Notably, lack of decision making for women was significantly associated with low knowledge, low or no formal education and increased age. In this study we noted that the high knowledge and intention to screen alone, did not translate into increased uptake. However, if combined with other interventions like communication strategies specifically targeting the men and women, male involvement, women empowerment and availability of community-based women friendly services among others, could help to translate into increased screening uptake. Further research on this is warranted. Knowledge alone does not translate to screening uptake, but a combination of approaches should be the focus of any communication strategy towards elimination of cervical cancer. Abbreviations HPV: Human papilloma virus Hr HPV: High risk human papilloma virus PRESCRIP-TEC: Prevention and screening innovation project towards elimination of cervical cancer. SSA: Sub-Sahara Africa VHT: Village health teams WHO: World Health Organization. Declarations Ethics approval and consent to participate . Ethical clearance was obtained from the Uganda Cancer Institute Research Ethics Committee ( registration number: UCI-2021-29) and the Uganda National Council for Science and Technology review ( registration number: HS2222ES) boards. We obtained administrative clearance from the district authorities of both Kakumiro and Kagadi districts to access their communities and conduct the research. All literate participants provided a written informed consent, in English or Runyoro - Kitara. Informed consent was obtained from legally authorised representatives/guardians for illiterate participants. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analysed during the current study are available in the open data source depository under DataverseNL. The registration number is https://doi.org/10.34894/LO4AA6 @data{LO4AA6_2024, author = {Koot, Jaap and Schans, Jurjen van der and Zeeuw Janine de}, publisher = {DataverseNL}, title = {{Prevention and Screening Innovation Project Towards Elimination of Cervical Cancer}}, year = {2024}, version = {DRAFT VERSION}, doi = {10.34894/LO4AA6}, url = {https://doi.org/10.34894/LO4AA6} Competing Interests The authors declare they have no competing interests. Funding This project has received funding from the European Union’s Horizon 2020 research and innovation program grant agreement No. 964270 and from the Ministry of Science and Technology, Department of Biomedical Technology in India, grant No 13213, under the Global Alliance for Chronic Diseases. Author ’ s contributions JS, JDZ, JJB, MF, CN, OJ, NM, MM and JK contributed to the initial conception and further research design of the project. CN, JDZ, AD, JK, MF, JJB, JS contributed to initial manuscript preparation. Authors contributed to revisions to the manuscript. All authors reviewed the manuscript and approved the final version for publication. Acknowledge ment The authors would like to express their gratitude to all women and men that participated in this study and willingly shared their opinions and beliefs with us. Our thanks and appreciation go out to the Village health teams of the participating villages and staff of the Ugandan Rural Development and Training Program. We also appreciate Uganda Cancer Institute for all the support rendered. References WHO: Global Strategy to accelerate the elimination of cervical cancer as a public health problem. 2020. Moodley J, Constant D, Mwaka AD, Scott SE, Walter FM [2021] Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa ecancer 15 1171 Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecol Oncol Rep. 2017 Feb 3;20:37-40. doi: 10.1016/j.gore.2017.01.009. PMID: 28275695; PMCID: PMC5331149. Mukama T, Ndejjo R, Musabyimana A, Halage AA, Musoke D. Women’s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in eastern Uganda. BMC Womens Health. 2017;17[1]:9. https://doi.org/10.1186/s12905-017-0365-3. Wabinga HR, Nambooze S, Amulen PM, Okello C, Mbus L, Parkin DM. Trends in the incidence of cancer in Kampala, Uganda 1991-2010. Int J Cancer.2014;135[2]:432–9. https://doi.org/10.1002/ijc.28661. Asasira J, Lee S, Tran TXM, Mpamani C, Wabinga H, Jung SY, et al.,. Infection-related and lifestyle-related cancer burden in Kampala, Uganda: projection of the future cancer incidence up to 2030. BMJ Open. 2022 Mar 16;12[3]:e056722. doi: 10.1136/bmjopen-2021-056722. PMID: 35296484; PMCID: PMC8928275. Nielson CM, Flores R, Harris RB, Abrahamsen M, Papenfuss MR, Dunne EF, Markowitz LE, Giuliano AR: Human Papillomavirus Prevalence and Type Distribution in Male Anogenital Sites and Semen. Cancer Epidemiol Biomarkers Prev 2007, 16[6]:1107 14[http://cebp.aacrjournals.org/content/16/ 6/1107.abstract - target-2]. Twinomujuni C, Nuwaha F, Babirye JN. Understanding the Low level of cervical cancer screening in Masaka Uganda using the ASE model: a community-based survey. PLoS One. 2015;10[6]:e0128498. Chapola J ,Lee F, Bula A, Mapanje,C, Phiri BR, Kamtuwange, N et al., Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study. BMJ Open 2021;11:e049901. doi:10.1136/bmjopen-2021-049901. de Fouw M, Stroeken Y, Niwagaba B, Musheshe M, Tusiime J, Sadayo I, et al. [2023] Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda. PLoS ONE 18[1]: e0280052. https://doi.org/10.1371/journal.pone.0280052 Mwaka AD , Okello ES , Wabinga H , et al . Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country. BMC Womens Health 2015; 15 :15. doi:10.1186/s12905-015-0167-4 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25783641 OpenUrlPubMedGoogle Scholar Mwaka AD , Wabinga HR , Mayanja-Kizza H . Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict Northern Uganda. BMC Fam Pract 2013; 14 :193. doi:10.1186/1471-2296-14-193 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24341601 OpenUrlPubMedGoogle Scholar Mwaka AD, Walter FM, Scott S, et al. Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer. BMJ Open 2021;11:e041365. doi:10.1136/ bmjopen-2020-041365 Black E, Hyslop F and Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda : a systematic review. BMC Women's Health [2019] 19:108 https://doi.org/10.1186/s12905-019-0809-z. Sultanov, M., Zeeuw, J.d., Koot, J. et al. Investigating feasibility of 2021 WHO protocol for cervical cancer screening in under screened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer [PRESCRIP-TEC]. BMC Public Health 22, 1356 [2022]. https://doi.org/10.1186/s12889-022-13488-z Uganda cervical cancer control strategic plan 2010 -2014. Mays DC, O’Neil EJ, Mworozi EA, Lough BJ, Tabb ZJ, Whitlock AE, Mutimba EM, Talib ZM. Supporting and retaining village Health teams: an assessment of a community health worker program in two Ugandan districts. Int J Equity Health. 2017;16(1):129. https://doi.org/10.1186/s12939-017-0619-6 MoH. Second National Health Policy: Promoting People's Health to Enhance Socio-economic Development. Kampala: Ministry of Health; 2010. p. 44. From http://library.health.go.ug/publications/leadership-and-governancegovernance/ policy-documents/national-health-policy. Accessed on 14 Apr 2018. MoH: Guidelines to the Local Government Planning Process Health Sector Supplement. Edited by Uganda MoH. Kampala: Ministry of Health;2019:70. From http://library.health.go.ug publications/guidelines/guidelines-localgovernment- planning-process-health-sector-supplement-july. Accessed on 15 Oct 2019. MoH: HEALTH SECTOR STRATEGIC & INVESTMENT PLAN: Promoting People’s Health to Enhance Socio-economic Development. 2010/11–2014/15. Kampala: Ministry of Health; 2010. From http://library.health.go.ug/ publications/policy-documents/health-sector-strategic-investment-planpromoting- people%E2%80%99s-health. Accessed on 27 Oct 2020. Nanyonjo A, Kertho E, Tibenderana J, Källander K. District Health Teams’ readiness to institutionalize integrated community case Management in the Uganda Local Health Systems: a repeated qualitative study. Global Health Sci Pract. 2020;8(2):190–204. https://doi.org/10.9745/GHSP-D-19-00318. MoH: Master Health Facilities Inventory. 2012. From http://library.health.go. ug/sites/default/files/resources/Health%20Facility%20Inventory%20update%20july%202012.pdf. Accessed on 20 May 2018. MoH: Strategic plan for cervical cancer prevention and control in Uganda 2010–2014. Edited by Health. Kampala: Ministry of Health; 2010:70. From http://www.iccp-portal.org/system/files/plans/PATH_Uganda_cxca_strat_plan_2010-2014.pdf. Accessed on 15 Apr 2018 Moodley J, Scott SE, Mwaka AD, Constant D, Githaiga JN, Stewart TS, et al. Development and validation of the African Women Awareness of CANcer (AWACAN) tool for breast and cervical cancer. PloS one. 2019;14(8): e0220545. Adoch, W., Garimoi, C.O., Scott, S.E. et al. Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda. Confl Health 14 , 85 [2020]. https://doi.org/10.1186/s13031-020-00328-3.29. Moshi FV, Bago M, Ntwenya J, Mpondo B, Kibusi SM. Uptake of Cervical Cancer Screening Services and Its Association with Cervical Cancer Awareness and Knowledge Among Women of Reproductive Age in Dodoma, Tanzania: A Cross-Sectional Study. East Afr Health Res J. 2019;3[2]:105-114. doi: 10.24248/EAHRJ-D-19-00006. Epub 2019 Nov 29. PMID: 34308203; PMCID: PMC8279286. Moshi FV, Bago M, Ntwenya J, Mpondo B, Kibusi SM. Uptake of Cervical Cancer Screening Services and Its Association with Cervical Cancer Awareness and Knowledge Among Women of Reproductive Age in Dodoma, Tanzania: A Cross-Sectional Study. East Afr Health Res J. 2019;3[2]:105-114. doi: 10.24248/EAHRJ-D-19-00006. Epub 2019 Nov 29. PMID: 34308203; PMCID: PMC8279286. Moodley J, Constant D, Mwaka AD, Scott SE, Walter FM [2020] Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa. PLoS ONE 15[10]: e0240788. https://doi.org/10.1371/journal.pone.0240788 Yimer NB, Mohammed MA, Solomon K, Tadese M, Grutzmacher S, Meikena HK, et al.,. Cervical cancer screening uptake in Sub-Saharan Africa: a systematic review and meta-analysis. Public Health. 2021 Jun;195:105-111. doi: 10.1016/j.puhe.2021.04.014. Epub 2021 May 31. PMID: 34082174. Lott, B.E., Trejo, M.J., Baum, C. et al. Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model. BMC Public Health 20, 654 (2020). https://doi.org/10.1186/s12889-020-08777-4 Chigbu CO, Onyebuchi AK, Onyeka TC, Odugu BU, Dim CC. The impact of community health educators on uptake of cervical and breast cancer prevention services in Nigeria. Int J Gynaecol Obstet. 2017;137(3):319–24. Mbachu C, Dim C, Ezeoke U. Effects of peer health education on perception and practice of screening for cervical cancer among urban residential women in south-East Nigeria: a before and after study. BMC Womens Health. 2017;17(1):41. Montano DE, Kasprzyk D. Theory of reasoned action, theory of planned behaviour, and the integrated behavioural model. Health Behaviour. 2015; 70(4):231. Ndikom CM, Ofi BA, Omokhodion FO, Adedokun BO. Effects of educational intervention on women’s knowledge and uptake of cervical cancer screening in selected hospitals in Ibadan, Nigeria. Int J Health Promot Educ. 2017;55(5–6):259–71. WHO fact sheet: Cervical cancer 17 th November 2023. Okyere J, Aboagye RG, Seidu AA, Asare BY, Mwamba B, Ahinkorah BO. Towards a cervical cancer-free future: women's healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa. BMJ Open. 2022 Jul 29;12(7):e058026. doi: 10.1136/bmjopen-2021-058026. PMID: 35906053; PMCID: PMC9345091. Glenn WJ, Matovu, JKB, Juncker, M; Namisango, E, Bouskill, K; Nakami, S, et al. Correlates of cervical cancer prevention advocacy and cervical cancer screening in Uganda: Cross-sectional evaluation of a conceptual model. Medicine 102[34]:p e34888, August 25, 2023. | DOI: 10.1097/MD.0000000000034888 Moses E, Pedersen HN, Mitchell SM, Sekikubo M, Mwesigwa D, Singer J, Biryabarema C, Byamugisha JK, Money DM, Ogilvie GS. Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial. Trop Med Int Health. 2015 Oct;20(10):1355-67. doi: 10.1111/tmi.12549. Epub 2015 Jun 28. PMID: 26031572. Rawat, A., Mithani, N., Sanders, C. et al. “We Shall Tell them with Love, Inform them what we have Learnt and then Allow them to go” - Men’s Perspectives of Self-Collected Cervical Cancer Screening in Rural Uganda: A Qualitative Inquiry. J Canc Educ 38 , 618–624 [2023]. https://doi.org/10.1007/s13187-022-02163-x Mutyaba T, Mirembe F, Sandin S, Weiderpass E. Male partner involvement in reducing loss to follow-up after cervical cancer screening in Uganda. IntJGynaecolObstet. 2009; 107[2]:103–6. https://doi.org/10. 1016/j.ijgo.2009.07.019 PMID: 19716557. Okeke EN, Adepiti CA, Ajenifuja KO. What is the price of prevention? New evidence from a field experiment. J Health Econ. 2013;32(1):207–18. Birhanu, Z., Abdissa, A., Belachew, T. et al. Health seeking behavior for cervical cancer in Ethiopia: a qualitative study. Int J Equity Health 11 , 83 [2012]. https://doi.org/10.1186/1475-9276-11-83 Abiodun OA, Olu-Abiodun OO, Sotunsa JO, Oluwole FA. Impact of health education intervention on knowledge and perception of cervical cancer and cervical screening uptake among adult women in rural communities in Nigeria. BMC Public Health. 2014;14:814. Gottschlich, A., Payne, B.A., Trawin, J. et al. Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial. Nat Med 29, 927–935 (2023). https://doi.org/10.1038/s41591-023-02288-6. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3849445","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":271081120,"identity":"bd66a808-ce37-40c5-9863-426d023d4742","order_by":0,"name":"Carolyn 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16:56:35","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":24236,"visible":true,"origin":"","legend":"","description":"","filename":"SUPPLEMENTARYMATERIAL.docx","url":"https://assets-eu.researchsquare.com/files/rs-3849445/v1/2f4603dd905f4e7b90b2d8db.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Baseline knowledge on risk factors, symptoms and intended behaviour of women and men towards screening and treatment of cervical cancer in rural Uganda: A cross-sectional study","fulltext":[{"header":"Background","content":"\u003cp\u003eWorldwide, cervical cancer is the fourth most common cancer among women and mainly affects women in low- and middle-income countries. Screening and treatment of pre-cancerous lesions are key to prevent cervical cancer effectively. The World Health Organization\u0026rsquo;s (WHO) elimination strategy recommends high risk Human Papilloma Virus (hrHPV) self-collected testing as primary screening because it is very sensitive, objective and highly accepted among women. It is a promising method to increase screening uptake [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUganda has one of the highest incidence and mortality rates due to cervical cancer. This has been attributed to low screening uptake which in turn is influenced by lack of knowledge about cervical cancer coupled with a poorly functioning health infrastructure [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] and high prevalence of risk factors among others [ 4 ]. The incidence of cervical cancer rose at a rate of 1.8% per year over a period of 20 years between 1991 to 2010 [5 ]. Incidence of cervical cancer was projected to increase by 35.3%, and Age Standardized Incidence Rates projected to increase up to 66.1 per 100 000 women by the year 2030, [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] if no intervention is put in place.\u003c/p\u003e \u003cp\u003eBeing a reproductive cancer, generally caused by infection with Human Papilloma Virus (HPV), prevention of cervical cancer is largely dependent on male support and involvement. Men play an important role in HPV transmission as HPV DNA has been detected in their genitalia ranging from 55.3\u0026ndash;76.6% among HIV positive men and 38.6\u0026ndash;47.6% among HIV negative men [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Furthermore, men are often decision makers in rural settings in Uganda and will often decide whether their women can be screened [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and treated for pre-cancerous lesions [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eLimited knowledge among men about the risk factors and causes of cervical cancer can limit uptake of screening. Good knowledge among men would enable them to embrace the prevention programmes and also to support and encourage the women to go for screening and to seek medical help on acquisition of symptoms of cervical cancer.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]\u003c/p\u003e \u003cp\u003ePoor recognition of cancer symptoms by both patients and primary healthcare professionals may contribute to the advanced stage at diagnosis and poor survival of cervical cancer patients in Uganda [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Ugandan women with vaginal symptoms often first attribute their symptoms to gynaecological infections such as candidiasis and sexually transmitted infections. Only if symptoms persist despite medications, then women sometimes attribute their symptoms to cancer [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The presence of symptoms usually implies advanced disease. Early recognition will aid in early diagnosis before advanced cancer is developed. Prevention of the cancer is key in the fight towards elimination.\u003c/p\u003e \u003cp\u003eKnowledge of the cause, risk factors and symptoms of cervical cancer are determinants of preventive behaviour such as screening and seeking medical help for early detection, which translates into reduction in the incidence, morbidity and mortality due to cervical cancer [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eInformation is needed on how best to design preventive interventions in the community.\u003c/p\u003e \u003cp\u003eThe Prevention and Screening Innovation Project Towards Elimination of Cervical cancer (PRESCRIP-TEC) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e] was initiated to evaluate the feasibility of the WHO strategy in resource-constrained circumstances and targets women living in rural areas in Uganda, Bangladesh and India.\u003c/p\u003e \u003cp\u003eAs part of the PRESCRIP-TEC project, the objective of this study was to gain understanding of the baseline cervical cancer knowledge and intended behaviour towards screening and treatment among women and men/decision makers in a rural community setting in Uganda, to enhance the specific communication strategy aimed at increasing uptake for cervical cancer screening and seeking help for early detection.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e\u003cb\u003eStudy Setting\u003c/b\u003e\u003c/h2\u003e \u003cp\u003eThe study was conducted from March 2022 to July 2022 in the districts of Kakumiro and Kagadi in Western Uganda. In both districts, 3 sub-counties were targeted in Kakumiro district and in Kagadi district.\u003c/p\u003e \u003cp\u003eEach of the sub-counties is served by at least one health centre III. Health centre III is the lowest level facility in the health structure where cervical cancer screening and treatment is carried out as per the national guidelines Strategic plan 2010\u0026ndash;2014 [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStudy population and Eligibility criteria\u003c/h2\u003e \u003cp\u003eWomen were included if they were aged 30\u0026ndash;49 years old, able to participate in a screen and treat programme, able to give informed consent for participation in the study and had the skills to respond to questions. The age limits align with the Uganda national cervical cancer screening guidelines. Women were excluded if they were pregnant, had history of hysterectomy, had prior treatment for cervical disease or had signs and symptoms of cervical cancer.\u003c/p\u003e \u003cp\u003eMen (husbands/decision makers of the women from the same households) aged 20\u0026ndash;70 years with skills to respond to questions and or engage in an interview were included. Men who refused or were unable to provide informed consent were excluded.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and Sampling\u003c/h2\u003e \u003cp\u003eThis was a cross-sectional study and sampling was non-randomised. The sub-counties in Kakumiro district were purposively selected for having no cervical cancer screening services available while those in Kagadi district were randomly selected because screening was available. The sample size was arrived at by calculating differences in awareness scores of at least 10% between women and men, applying a two-sided two-sample test with alpha\u0026thinsp;=\u0026thinsp;0.05, a standard deviation of 0.2 and allowing for a 15% non-response rate. We targeted 400 women and their male counterparts from each of the districts.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe Village Health Teams (VHTs) provide the first level of primary health care in Uganda. The teams consist of community volunteers, both women and men, chosen by community members to provide healthcare services to their communities and are regarded as Health Centre I (HC I) [ 17, 18,19]. Each VHT serves about 1000 people or 25 households in a village [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], and they provide linkage between the community and the HCs [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In addition to other functions, the VHTs are to raise awareness and mobilise community members to participate in cervical cancer prevention activities [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. For each sub-county prior to data collection, 12 VHTs were trained for a period of 5 days by the principal investigator (CN). The training included the basics of cervical cancer, the cause, risk factors, symptoms, signs and prevention of cervical cancer. VHTs were also trained on the research protocol, Good Clinical Practice, the consenting process and the questionnaire. VHTs were selected by the Head VHT based on literacy levels. They collected data from one village at a time until; all homesteads were visited. All interviews were conducted in the homes of the women and her husbands/decision makers after establishing eligibility and informed consent obtained. Data was initially collected on paper questionnaires and later double entered into the REsearch Data Capturing system (REDcap) by data entry clerks. Data was checked for completeness and as part of quality control, the research assistants revisited the households when data was not complete and or aspects of the data were not clear.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eInstruments\u003c/h2\u003e \u003cp\u003eIn order to measure cervical cancer awareness and intended behaviour, the adapted version of the African Women Awareness of CANcer (AWACAN) instrument was administered. The AWACAN tool has shown to be reliable and valid for use in Sub-Saharan Africa. It is a 41-item questionnaire that measures women\u0026rsquo;s awareness of cervical cancer. The tool measures awareness in the following domains: risk factors, symptoms, lay beliefs, confidence in appraisal, health-seeking behaviours, and barriers to health care and has socio-demographic questions [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. The questionnaire was validated with questions on knowledge of risk factors and symptoms of cervical cancer, help-seeking behaviour, confidence skills and behaviour regarding symptoms and barriers to seeking help. Prior to data collection, the instrument was pilot tested and forward and backward translation to Runyoro-Kitara language done. Based on the pilot, separate versions for women and their husbands or household decision makers were prepared.\u003c/p\u003e \u003cp\u003eThe AWACAN questionnaire assessed 11 risk factors and 12 symptoms of cervical cancer. Knowledge of risk factors was only assessed on respondents who had ever heard of cervical cancer while symptoms were assessed on the total sample included as per the AWACAN tool.\u003c/p\u003e \u003cp\u003eTo assess intended behaviour, we measured health-seeking behaviour, confidence in identifying signs and symptoms and barriers to seeking medical help. Health seeking behaviour was assessed using 6 questions. Confidence in identifying signs and symptoms of cervical cancer was measured using 3 questions. Barriers to seeking medical help was measured using 12 questions.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eThe collected data was coded, entered and analysed using Statistical Package for Social Sciences version 26.\u003c/p\u003e \u003cp\u003eUnivariate analysis was done to obtain the descriptive statistics (demographic characteristics) of the participants. Bivariate analysis and comparison of all AWACAN question responses between female respondents and men was done. Measures on knowledge scores included median and interquartile ranges. Knowledge scores were categorised into binary outcome as less knowledgeable below the median scores and highly knowledgeable with median and above the median scores. Bivariate analysis using Chi square tests were conducted to determine associations between the binary knowledge scores on risk factors and symptoms of cervical cancer with socio-demographic correlates. Multivariate logistic regression models were applied on categorical variables to determine the magnitude of association between knowledge of risk factors and symptoms of cervical cancer with the demographic factors. We also checked for the assumptions.\u003c/p\u003e \u003cp\u003eStatistical significance was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. Odds ratios and accompanying 95% confidence intervals stated.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic characteristics of the participants\u003c/h2\u003e \u003cp\u003eA total of 1,416 participants, 724 (51.1%) women and 692 (48.9%) men were interviewed. More than half of them were less than 40 years old with a mean age of 37 years for the female respondents and 38 years for the male respondents. See Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSocio demographic characteristics of participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemale N\u0026thinsp;=\u0026thinsp;724\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMale N\u0026thinsp;=\u0026thinsp;692\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.39 (5.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e37.88 (7.13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 [16.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e71 [16.1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary School\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e325 [76.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e335 [75.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 [7.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 [7.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTertiary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 [0.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e312 [63.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e272 [ 62.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 [9.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56 [ 12.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWidowed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 [3.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13 [ 3.0]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 [21.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90 [ 20.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDivorced\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 [1.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8 [ 1.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eEver heard of cervical cancer?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e510 [ 71.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e459 [67.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e208 [ 29.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e224 [ 32.8]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHas a health worker ever tested you for cervical cancer?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61 [ 8.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e633 [91.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRefused\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [ 0.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon\u0026rsquo;t know\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 [0.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003eWho makes decisions concerning your health?\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyself\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e229 [31.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMy partner\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e254 [ 35.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyself and partner jointly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e226 [31.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSomeone else in the household\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 [ 1.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMyself and someone else jointly\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [ 0.3]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNA\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge on risk factors of cervical cancer\u003c/h2\u003e \u003cp\u003eKnowledge of risk factors for cervical cancer was assessed in 510 women and 459 men. These are participants who responded positively to ever having heard of cervical cancer. HPV infection being a risk factor for cervical cancer was known by 74.5% of the women and 72.2% of the men. Having many sexual partners was recognised by 82.9% women and 78.8% men, while smoking was recognised by only 55.6% of the women and 54.5% of the men. Giving birth to more than 3 children was the only risk factor with significant difference in knowledge between men and women; the women were more knowledgeable than the men. See details in supplementary material Table\u0026nbsp;1.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge on symptoms of cervical cancer\u003c/h2\u003e \u003cp\u003eKnowledge on symptoms and/or signs of cervical cancer was assessed in 724 women and 692 men. A persistent smelly vaginal discharge was the commonest recognised symptom of cervical cancer while persistent diarrhoea was the least recognised symptom. The women were 8 times more likely to recognise lower back pain as a symptom of cervical cancer than the men. See details in supplementary material Table\u0026nbsp;2.\u003c/p\u003e \u003cp\u003eK\u003cb\u003enowledge scores on risk factors and symptoms\u003c/b\u003e\u003c/p\u003e \u003cp\u003eA total of 510 women and 459 men were assessed on 11 risk factors for cervical cancer. The median number of risk factors recognised was 8 (IQR 6\u0026ndash;10) for both women and men; 60% of the women and 57.4% of the men could recognise 8\u0026ndash;11 risk factors, 22 (4.3%) of the women and 33 (7.2%) of the men couldn\u0026rsquo;t recognise a single risk factor for cervical cancer.\u003c/p\u003e \u003cp\u003eOf the 724 women and 692 men assessed on recognition of symptoms, 64.6% and 60.5% respectively could recognise 8\u0026ndash;12 symptoms out of the 12 symptoms, while 67 (9.3%) women and 71(10.3%) men couldn\u0026rsquo;t identify a single symptom of cervical cancer. Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge scores of cervical cancer risk factors and symptoms.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge scores\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRisk factors = 510\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;724\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRisk factors\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;459\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;692\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedian score [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], IQR [6.0\u0026ndash;10.0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65 ( 12.8%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (12.0%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e43 (9.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e64 (9.2%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBelow median score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202 (39.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e256 (35.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e196 (42.7%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e273 (39.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove median score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e243 (47.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e381 (52.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e220 (47.9%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e355 (51.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eKey: Interquartile range (IQR).\u003c/b\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eAssociation between knowledge of risk factors and symptoms of cervical cancer with social demographic characteristics.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eAge, Education attainment and marital status were all not associated with knowledge of risk factors and symptoms for cervical cancer for both the women and the men. See supplementary information Tables\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e and \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDecision making in comparison with other factors\u003c/h2\u003e \u003cp\u003eWomen whose husbands/decision makers made decisions for them with regard to issues of health were 15 times likely to be less knowledgeable about risk factors of cervical cancer compared to women who made their own decisions or in partnership with their husbands. They were also more likely to be older and less or not educated. Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDecision making in comparison with other factors.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMyself\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePartner\u003c/p\u003e \u003cp\u003en(%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMyself and Partner\u003c/p\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk factors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52 (32.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e74 (45.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e66 (37.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e14.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108 (67.18)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e90 (54.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e109 (62.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSymptoms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e48 (27.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e52 (29.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e64 (33.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e2.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.72\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh knowledge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e124 (72.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e125 (70.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e130 (67.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e30\u0026ndash;39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61 (79.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e59 (65.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e61 (55.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e17.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u0026ndash;49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16 (20.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e31 (34.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e49 (44.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEducation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e20 (12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12 (7.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e25 (14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e36.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10 (6.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e4 (2.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e6 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42 (26.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e56 (34.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e60 (34.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e5 (3.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18 (11.0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e20 (11.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eKey: CP \u0026ndash; Completed Primary school, CS \u0026ndash; Completed secondary school, LP \u0026ndash; Didn\u0026rsquo;t complete primary school, None \u0026ndash; No formal education, X\u003csup\u003e2\u003c/sup\u003e - Chi square.\u003c/p\u003e \u003cp\u003e \u003cb\u003eKnowledge of risk factors, symptoms and intended behaviour towards cervical cancer among women and men.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThere was no significant difference between the women and men in their knowledge of risk factors and symptoms. However, men had better health seeking behaviour than women, and more confidence, skills and behaviour towards signs and symptoms of cervical cancer. See details in supplementary table 5.\u003c/p\u003e \u003cp\u003eBarriers to seeking medical help were found in 316 (43.9%) of the women and 314 (45.4%) men but there was no difference between the two groups, neither did barriers affect them significantly. See details in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and supplementary table 5.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eKnowledge of risk factors, symptoms of cervical cancer and intended behaviour among men and women\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFemales\u003c/p\u003e \u003cp\u003en [%]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMales\u003c/p\u003e \u003cp\u003en [%]\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eX\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKnowledge of cervical cancer risk factors\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;969\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e154\u003c/p\u003e \u003cp\u003e[30.2]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e196 [42.7]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.74\u0026ndash;1.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e356\u003c/p\u003e \u003cp\u003e[69.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e263 [ 57.3]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eKnowledge of cervical cancer symptoms\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1416\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLow score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e256\u003c/p\u003e \u003cp\u003e[35. 4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e273 [ 39.5 ]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e2.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.96\u0026ndash;1.48\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHigh score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e468\u003c/p\u003e \u003cp\u003e[64.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e419 [60.5]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eHelp seeking behaviour\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1409\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e313\u003c/p\u003e \u003cp\u003e[43.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e161\u003c/p\u003e \u003cp\u003e[23.30]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e64.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.393\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.312\u0026ndash;0.495\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e405\u003c/p\u003e \u003cp\u003e[56.4]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e530 [76.7]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eConfidence skills and behaviour to a sign or symptom\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1407\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e221\u003c/p\u003e \u003cp\u003e[30.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e130\u003c/p\u003e \u003cp\u003e[18.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e27.28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.40\u0026ndash;0.67\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e495\u003c/p\u003e \u003cp\u003e[69.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e561 [81.2]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eBarrier to seeking help\u003c/p\u003e \u003cp\u003en\u0026thinsp;=\u0026thinsp;1411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e404\u003c/p\u003e \u003cp\u003e[56.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e377\u003c/p\u003e \u003cp\u003e[54.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c7\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e1.07\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.86\u0026ndash;1.31\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e316\u003c/p\u003e \u003cp\u003e[43.9]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e314\u003c/p\u003e \u003cp\u003e[45.4]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eKey: Odd\u0026rsquo;s ratio - OR; Confidence Interval - CI\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis community-based study provides information on baseline knowledge of risk factors and symptoms of cervical cancer and intended behaviour towards screening and treatment for cervical cancer of women and men living in rural Uganda. We found that knowledge of risk factors and symptoms was high in the majority of participants, with no difference between the women and the men. We also found that despite this high knowledge, intended behaviour to screen and the apparent insignificant barriers, the screening uptake was very low necessitating further investigation into this discrepancy.\u003c/p\u003e \u003cp\u003eResults from this study can inform specific target group communication and other implementation strategies on cervical cancer prevention aimed at increasing uptake for screening and early detection.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge on cervical cancer\u003c/h2\u003e \u003cp\u003eIn our study, there was no association between the demographic factors and knowledge of risk factors and symptoms, probably because the population was generally uniform with no significant differences with regard to their demographic characteristics and knowledge of cervical cancer. This is unlike other studies where low knowledge of risk factors was associated with not being married [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and low education [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. In another study the level of education was associated with high knowledge for risk factors while older age was associated with symptom awareness [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMore than 60% of both women and men were able to recognize at least 8 out of 11 and 12 risk factors and symptoms respectively of cervical cancer, making it a knowledgeable population with no difference between the women and men. Knowledge of risk factors promotes preventative behaviour like screening and vaccination against HPV while knowledge of the symptoms promotes health seeking behaviour and thus early detection.\u003c/p\u003e \u003cp\u003eIt is known that knowledge of cervical cancer is a determinant of screening uptake [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e], but the knowledge of the participants in this study was not commensurate with the level of uptake. This reciprocates with the review by Lott et al., where they analysed interventions to increase uptake of cervical screening in Sub-Saharan Africa (SSA) and found that educational interventions were the most common type of intervention used to increase uptake of cervical screening in SSA but also the least effective [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, a few studies that utilised peer health educators and community health educators as part of the implementation strategy were an exception emphasising the role of social ties, using educators that were already known to the study participants [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This means that education as an intervention may not yield much. But if delivered by peers and community health educators it may influence screening uptake. In addition, education needs to be combined with actual availability of the appropriate services. This was noted in our study areas where knowledge of the respondents was high in both districts, but uptake was 6.6% in the district with no services and 11.1% in the district with services. This difference was not significant but notably more women had been screened in the latter and the few women who had been screened in the former could have sourced it in another district.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eIntended behaviour\u003c/h2\u003e \u003cp\u003eThe Integrated Behavioural model (IBM) is hinged on the fact that the most important determinant of behaviour is intention to perform that behaviour, and that intention is influenced by attitudes, perceived norms and personal agency [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. In our study the high knowledge and good intended behaviour did not translate into screening behaviour. Lott et al observed very high willingness to screen but that intent to screen did not always translate into uptake of cervical screening [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Similarly, Ndikom et al., described an increase from 75.8\u0026ndash;91% in willingness to screen, yet no change in actual screening was observed [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Therefore, intended behaviour alone does not guarantee behaviour change. More research is required to find out what more needs to be done to allow this intention to translate into actual screening uptake.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eDecision making\u003c/h2\u003e \u003cp\u003eWe found that the women who took no part and depended on their husbands to make decisions concerning their health were least knowledgeable about risk factors of cervical cancer, followed by those who decided in partnership with their husbands, while the women who made their own decisions were most knowledgeable of all the women.\u003c/p\u003e \u003cp\u003eIn addition, women whose husbands made decisions for them were least educated or mostly with no formal education at all and were also older putting them at most risk for cervical cancer [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. The trend was similar in those who made decisions in partnership with their husbands and were next at risk. The women who made their own decisions were more knowledgeable on risk factors, most educated and younger than the two groups. This is in agreement with another study on women\u0026rsquo;s healthcare decision making and cervical cancer screening uptake done in 4 countries in SSA, in which showed that women who are able to make autonomous healthcare decisions were most likely to uptake cervical cancer screening followed by those who decided in partnership with their husbands and least of all were those whose decisions were solely made by their husbands. [ 35].\u003c/p\u003e \u003cp\u003eNdikom et al., [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] in their study in Nigeria reported lack of decision-making ability as a barrier to screening. Formal education and training were found to be key to raising women\u0026rsquo;s confidence as was reported in the Wagner study [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Building confidence in those women was demonstrated to have a multiplying effect in getting women to screen. In their pilot, women who had screened were trained as advocates for cervical cancer screening and this resulted in increased numbers of women taking up screening. [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Therefore, policy interventions should focus on empowering women to make autonomous decisions or in partnership with their husbands with regard to issues concerning health.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eMale involvement\u003c/h2\u003e \u003cp\u003eIn this study, 60% of the women had decisions made for them by the men or in partnership with them. Men play a role in the transmission of the HPV infection. This makes men a critical target for impactful communication and other interventions aimed at increasing screening uptake. Men and their involvement in the control of cervical cancer are key players in the elimination of cervical cancer [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this study men had significant better health seeking behaviour compared to the women. This could be attributed to the fact that health seeking is associated with certain expenses such as transport and medical costs. Since men generally are the bread earners and decision makers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], they usually control the budget to spend rather than the women. If men are better educated about risk factors and symptoms of cervical cancer, they are more willing to support their wives in providing support for cervical cancer screening. This is supported in various studies where men were willing to support their wives to seek help in case of symptoms and also willing to support them for screening [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Other studies have tried integrating male services into cervical cancer screening programs with some positive results [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. This could be an area for more research.\u003c/p\u003e \u003cp\u003eAdditionally, men felt more confident at recognizing a symptom of cervical cancer than the women. This could be attributed to a cultural norm where the men are the decision makers and thus expected to know more than the women, or a possible socially desirable response. Increasing community knowledge of cervical cancer symptoms among others and tackling perceived barriers to health seeking, could lead to prompt and appropriate symptom appraisal and help seeking and contribute to improved cancer outcomes.\u003c/p\u003e \u003cp\u003eGiven more education on cervical cancer and the role they can play in preventing it, combined with targeted communication messages and active involvement, men would significantly impact on screening uptake which would in turn contribute towards elimination of cervical cancer.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eBarriers\u003c/h2\u003e \u003cp\u003eTransport as a barrier to seeking medical help did not feature significantly but more than 40% of the women reported it was a problem. Therefore economic empowerment of the women so that they do not depend on the men, could possibly influence them to taking up screening for cervical cancer since lack of transport has been cited to be a barrier to screening in several studies [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. However, economic incentives to women increased uptake very minimally of less than 20% [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. This intervention may not work and let alone be sustainable. It may need to be coupled with other interventions.\u003c/p\u003e \u003cp\u003eBarriers to seeking medical help were surprisingly lower in our study compared to other studies probably because the respondents were aware of most of the risks and symptoms of cervical cancer and the advantage of seeking medical help. More than half of the participants both women and men would seek medical help once there are symptoms. This is in contrast with the study by Birhanu et al., [\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] where cervical cancer was associated with a lot of stigmas. It was thought that frequent sex with multiple partners was the cause. Afraid of stigma, women shied away from seeking help. Issues like long waiting time, fear of the diagnosis, lack of transport and others did not feature as obstacles to seeking medical help in more than half of the participants in our study contrary to what was previously reported [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eService availability\u003c/h2\u003e \u003cp\u003eIn the review by Lott et. al, studies that utilised innovative service delivery approaches focusing on availability, accessibility and appropriateness of screening services for women resulted in the greatest increases in screening uptake. [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. At the time of this study, there were no screening services in the entire district which would explain the low uptake confirming availability of services to be crucial in enabling behaviour to screen. [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]\u003c/p\u003e \u003cp\u003eIn another study, accessibility was addressed by changing location of the screening services from health facilities and bringing them to the doorsteps of the women avoiding transport as a barrier. This led to tremendous increase in screening uptake which was not possible when women were referred to hospital for screening [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. Community based service delivery addressed the issue of accessibility. We recommend this approach as it has been proved to yield increase in screening uptake.\u003c/p\u003e \u003cp\u003eUptake was even higher when the test was switched from Visual Inspection with Acetic acid (VIA) to self-collection. In Uganda and other places, self-collection registered uptake higher than 90% and the women reported very good attitude towards this type of screening. Coupled by integration into existing services and having community health workers drive the project was acceptable by the women because of working with their own well known community healthcare workers and feeling in charge of their own health given the technique of self-collection in the comfort and privacy of their homes. This made the service delivery women friendly/appropriate and resulted into screening uptake of more than 90% [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. We therefore recommend this proven women friendly approach of self-collection in their homes by community health workers and anticipate an increase in the screening uptake in this community.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and limitations\u003c/h2\u003e \u003cp\u003eThis study was conducted by trained local VHTs who spoke the local language and knew the homes of all the residents ensuring coverage of the area. The willingness of men who are decision makers to be involved in the prevention and early detection of cervical cancer for their wives is an advantage for the next phase of intervention of this study. Another advantage was the fact that the study was conducted in a very rural place which may be similar and may be representative of many of the other parts of the country in Uganda. The other strength of this study is that we investigated the intended behaviour of the men which greatly informs policy on intervention.\u003c/p\u003e \u003cp\u003eThe sample size of 1,416 participants was less than was calculated due to the fact that the study was conducted during the rainy season, making it sometimes difficult to find potential participants. This however has enough power to draw conclusions from the results generated.\u003c/p\u003e \u003cp\u003eAmong the limitations, social desirability cannot be ruled out given that the questionnaires were administered face to face. This was minimised by the fact that the VHTs were adequately trained and emphasised to the participants that their responses were going to be kept anonymous with confidentiality and privacy observed.\u003c/p\u003e \u003cp\u003eThere was a degree of selection bias given that the sub-districts in the intervention areas were selected by community and political leaders on the basis that there were no screening services in those areas. However we think that results would have been similar if another area had been selected for the study within the same region. This was minimised by ensuring that all villages and all households with eligible participants were included in the study with the help of the local VHTs.\u003c/p\u003e \u003cp\u003eAnother disadvantage of this study is the lack of a standardized knowledge assessment questionnaire which limits the comparability of the findings across studies carried out in the region, but the findings of which can be used to develop target specific messages on cervical cancer prevention and early detection.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eKnowledge of risk factors and symptoms and signs of cervical cancer in the majority of participants was high in both women and men with no significant difference between the two groups. The intended behaviour for both women and men towards screening or early diagnosis and early detection was generally positive. Barriers to seeking medical help didn\u0026rsquo;t significantly affect the population to go for screening and yet despite all the above factors, screening uptake was very low. Notably, lack of decision making for women was significantly associated with low knowledge, low or no formal education and increased age.\u003c/p\u003e \u003cp\u003eIn this study we noted that the high knowledge and intention to screen alone, did not translate into increased uptake. However, if combined with other interventions like communication strategies specifically targeting the men and women, male involvement, women empowerment and availability of community-based women friendly services among others, could help to translate into increased screening uptake. Further research on this is warranted. Knowledge alone does not translate to screening uptake, but a combination of approaches should be the focus of any communication strategy towards elimination of cervical cancer.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eHPV: Human papilloma virus\u003c/p\u003e\n\u003cp\u003eHr HPV: High risk human papilloma virus\u003c/p\u003e\n\u003cp\u003ePRESCRIP-TEC: Prevention and screening innovation project towards elimination of cervical cancer.\u003c/p\u003e\n\u003cp\u003eSSA: Sub-Sahara Africa\u003c/p\u003e\n\u003cp\u003eVHT: Village health teams\u003c/p\u003e\n\u003cp\u003eWHO: World Health Organization.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from the Uganda Cancer Institute Research Ethics Committee ( registration number: UCI-2021-29) and the Uganda National Council for Science and Technology review ( registration number: HS2222ES) boards. We obtained administrative clearance from the district authorities of both Kakumiro and Kagadi districts to access their communities and conduct the research. All literate participants provided a written informed consent, in English or Runyoro - Kitara. Informed consent was obtained from legally authorised representatives/guardians for illiterate participants.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analysed during the current study are available in the open data source depository under DataverseNL.\u003c/p\u003e\n\u003cp\u003eThe registration number is https://doi.org/10.34894/LO4AA6\u003c/p\u003e\n\u003cp\u003e@data{LO4AA6_2024,\u003c/p\u003e\n\u003cp\u003eauthor = {Koot, Jaap and Schans, Jurjen van der and Zeeuw Janine de},\u003c/p\u003e\n\u003cp\u003epublisher = {DataverseNL},\u003c/p\u003e\n\u003cp\u003etitle = {{Prevention and Screening Innovation Project Towards Elimination of Cervical Cancer}},\u003c/p\u003e\n\u003cp\u003eyear = {2024},\u003c/p\u003e\n\u003cp\u003eversion = {DRAFT VERSION},\u003c/p\u003e\n\u003cp\u003edoi = {10.34894/LO4AA6},\u003c/p\u003e\n\u003cp\u003eurl = {https://doi.org/10.34894/LO4AA6}\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis project has received funding from the European Union\u0026rsquo;s Horizon 2020 research and innovation program grant agreement No. 964270 and from the Ministry of Science and Technology, Department of Biomedical Technology in India, grant No 13213, under the Global Alliance for Chronic Diseases.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u003c/strong\u003e\u0026rsquo;\u003cstrong\u003es contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJS, JDZ, JJB, MF, CN, OJ, NM, MM and JK contributed to the initial conception and further research design of the project. CN, JDZ, AD, JK, MF, JJB, JS contributed to initial manuscript preparation. Authors contributed to revisions to the manuscript. All authors reviewed the manuscript and approved the final version for publication.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledge\u003c/strong\u003e\u003cstrong\u003ement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to express their gratitude to all women and men that participated in this study and willingly shared their opinions and beliefs with us. Our thanks and appreciation go out to the Village health teams of the participating villages and staff of the Ugandan Rural Development and Training Program. We also appreciate Uganda Cancer Institute for all the support rendered.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO: Global Strategy to accelerate the elimination of cervical cancer as a public health problem. 2020.\u003c/li\u003e\n\u003cli\u003eMoodley J, Constant D, Mwaka AD, Scott SE, Walter FM [2021] Anticipated help seeking behaviour and barriers to seeking care for possible breast and cervical cancer symptoms in Uganda and South Africa \u003cem\u003eecancer\u003c/em\u003e 15 1171\u003c/li\u003e\n\u003cli\u003eNakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecol Oncol Rep. 2017 Feb 3;20:37-40. doi: 10.1016/j.gore.2017.01.009. PMID: 28275695; PMCID: PMC5331149.\u003c/li\u003e\n\u003cli\u003eMukama T, Ndejjo R, Musabyimana A, Halage AA, Musoke D. Women\u0026rsquo;s knowledge and attitudes towards cervical cancer prevention: a cross sectional study in eastern Uganda. BMC Womens Health. 2017;17[1]:9. https://doi.org/10.1186/s12905-017-0365-3.\u003c/li\u003e\n\u003cli\u003eWabinga HR, Nambooze S, Amulen PM, Okello C, Mbus L, Parkin DM. Trends in the incidence of cancer in Kampala, Uganda 1991-2010. Int J Cancer.2014;135[2]:432\u0026ndash;9. https://doi.org/10.1002/ijc.28661.\u003c/li\u003e\n\u003cli\u003eAsasira J, Lee S, Tran TXM, Mpamani C, Wabinga H, Jung SY, et al.,. Infection-related and lifestyle-related cancer burden in Kampala, Uganda: projection of the future cancer incidence up to 2030. BMJ Open. 2022 Mar 16;12[3]:e056722. doi: 10.1136/bmjopen-2021-056722. PMID: 35296484; PMCID: PMC8928275.\u003c/li\u003e\n\u003cli\u003eNielson CM, Flores R, Harris RB, Abrahamsen M, Papenfuss MR, Dunne EF, Markowitz LE, Giuliano AR: Human Papillomavirus Prevalence and Type Distribution in Male Anogenital Sites and Semen. Cancer Epidemiol Biomarkers Prev 2007, 16[6]:1107 14[http://cebp.aacrjournals.org/content/16/ 6/1107.abstract - target-2].\u003c/li\u003e\n\u003cli\u003eTwinomujuni C, Nuwaha F, Babirye JN. Understanding the Low level of cervical cancer screening in Masaka Uganda using the ASE model: a community-based survey. PLoS One. 2015;10[6]:e0128498. \u003c/li\u003e\n\u003cli\u003eChapola J ,Lee F, Bula A, Mapanje,C, Phiri BR, Kamtuwange, N et al., Barriers to follow-up after an abnormal cervical cancer screening result and the role of male partners: a qualitative study. BMJ Open 2021;11:e049901. doi:10.1136/bmjopen-2021-049901.\u003c/li\u003e\n\u003cli\u003ede Fouw M, Stroeken Y, Niwagaba B, Musheshe M, Tusiime J, Sadayo I, et al. [2023] Involving men in cervical cancer prevention; a qualitative enquiry into male perspectives on screening and HPV vaccination in Mid-Western Uganda. PLoS ONE 18[1]: e0280052. https://doi.org/10.1371/journal.pone.0280052\u003c/li\u003e\n\u003cli\u003eMwaka AD , Okello ES , Wabinga H , \u003cem\u003eet al\u003c/em\u003e . Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country. \u003cem\u003eBMC Womens Health\u003c/em\u003e 2015;\u003cstrong\u003e15\u003c/strong\u003e:15. doi:10.1186/s12905-015-0167-4 pmid:http://www.ncbi.nlm.nih.gov/pubmed/25783641 OpenUrlPubMedGoogle Scholar\u003c/li\u003e\n\u003cli\u003eMwaka AD , Wabinga HR , Mayanja-Kizza H . Mind the gaps: a qualitative study of perceptions of healthcare professionals on challenges and proposed remedies for cervical cancer help-seeking in post conflict Northern Uganda. \u003cem\u003eBMC Fam Pract\u003c/em\u003e 2013;\u003cstrong\u003e14\u003c/strong\u003e:193. doi:10.1186/1471-2296-14-193 pmid:http://www.ncbi.nlm.nih.gov/pubmed/24341601 OpenUrlPubMedGoogle Scholar\u003c/li\u003e\n\u003cli\u003eMwaka AD, Walter FM, Scott S, et al. Symptom appraisal, help-seeking and perceived barriers to healthcare seeking in Uganda: an exploratory study among women with potential symptoms of breast and cervical cancer. BMJ Open 2021;11:e041365. doi:10.1136/ bmjopen-2020-041365\u003c/li\u003e\n\u003cli\u003eBlack E, Hyslop F and Richmond R. Barriers and facilitators to uptake of cervical cancer screening among women in Uganda : a systematic review. BMC Women\u0026apos;s Health [2019] 19:108 https://doi.org/10.1186/s12905-019-0809-z. \u003c/li\u003e\n\u003cli\u003eSultanov, M., Zeeuw, J.d., Koot, J. \u003cem\u003eet al.\u003c/em\u003e Investigating feasibility of 2021 WHO protocol for cervical cancer screening in under screened populations: PREvention and SCReening Innovation Project Toward Elimination of Cervical Cancer [PRESCRIP-TEC]. \u003cem\u003eBMC Public Health\u003c/em\u003e 22, 1356 [2022]. https://doi.org/10.1186/s12889-022-13488-z\u003c/li\u003e\n\u003cli\u003eUganda cervical cancer control strategic plan 2010 -2014.\u003c/li\u003e\n\u003cli\u003eMays DC, O\u0026rsquo;Neil EJ, Mworozi EA, Lough BJ, Tabb ZJ, Whitlock AE, Mutimba EM, Talib ZM. Supporting and retaining village Health teams: an assessment of a community health worker program in two Ugandan districts. Int J Equity Health. 2017;16(1):129. https://doi.org/10.1186/s12939-017-0619-6\u003c/li\u003e\n\u003cli\u003eMoH. Second National Health Policy: Promoting People\u0026apos;s Health to Enhance Socio-economic Development. Kampala: Ministry of Health; 2010. p. 44. From http://library.health.go.ug/publications/leadership-and-governancegovernance/ policy-documents/national-health-policy. Accessed on 14 Apr 2018.\u003c/li\u003e\n\u003cli\u003eMoH: Guidelines to the Local Government Planning Process Health Sector Supplement. Edited by Uganda MoH. Kampala: Ministry of Health;2019:70. From http://library.health.go.ug publications/guidelines/guidelines-localgovernment- planning-process-health-sector-supplement-july. Accessed on 15 Oct 2019.\u003c/li\u003e\n\u003cli\u003eMoH: HEALTH SECTOR STRATEGIC \u0026amp; INVESTMENT PLAN: Promoting People\u0026rsquo;s Health to Enhance Socio-economic Development. 2010/11\u0026ndash;2014/15. Kampala: Ministry of Health; 2010. From http://library.health.go.ug/ publications/policy-documents/health-sector-strategic-investment-planpromoting- people%E2%80%99s-health. Accessed on 27 Oct 2020.\u003c/li\u003e\n\u003cli\u003eNanyonjo A, Kertho E, Tibenderana J, K\u0026auml;llander K. District Health Teams\u0026rsquo; readiness to institutionalize integrated community case Management in the Uganda Local Health Systems: a repeated qualitative study. Global Health Sci Pract. 2020;8(2):190\u0026ndash;204. https://doi.org/10.9745/GHSP-D-19-00318.\u003c/li\u003e\n\u003cli\u003eMoH: Master Health Facilities Inventory. 2012. From http://library.health.go. ug/sites/default/files/resources/Health%20Facility%20Inventory%20update%20july%202012.pdf. Accessed on 20 May 2018.\u003c/li\u003e\n\u003cli\u003eMoH: Strategic plan for cervical cancer prevention and control in Uganda 2010\u0026ndash;2014. Edited by Health. Kampala: Ministry of Health; 2010:70. From http://www.iccp-portal.org/system/files/plans/PATH_Uganda_cxca_strat_plan_2010-2014.pdf. Accessed on 15 Apr 2018\u003c/li\u003e\n\u003cli\u003eMoodley J, Scott SE, Mwaka AD, Constant D, Githaiga JN, Stewart TS, et al. Development and validation of the African Women Awareness of CANcer (AWACAN) tool for breast and cervical cancer. PloS one. 2019;14(8): e0220545.\u003c/li\u003e\n\u003cli\u003eAdoch, W., Garimoi, C.O., Scott, S.E. \u003cem\u003eet al.\u003c/em\u003e Knowledge of cervical cancer risk factors and symptoms among women in a refugee settlement: a cross-sectional study in northern Uganda. \u003cem\u003eConfl Health\u003c/em\u003e \u003cstrong\u003e14\u003c/strong\u003e, 85 [2020]. https://doi.org/10.1186/s13031-020-00328-3.29. Moshi FV, Bago M, Ntwenya J, Mpondo B, Kibusi SM. Uptake of Cervical Cancer Screening Services and Its Association with Cervical Cancer Awareness and Knowledge Among Women of Reproductive Age in Dodoma, Tanzania: A Cross-Sectional Study. East Afr Health Res J. 2019;3[2]:105-114. doi: 10.24248/EAHRJ-D-19-00006. Epub 2019 Nov 29. PMID: 34308203; PMCID: PMC8279286.\u003c/li\u003e\n\u003cli\u003eMoshi FV, Bago M, Ntwenya J, Mpondo B, Kibusi SM. Uptake of Cervical Cancer Screening Services and Its Association with Cervical Cancer Awareness and Knowledge Among Women of Reproductive Age in Dodoma, Tanzania: A Cross-Sectional Study. East Afr Health Res J. 2019;3[2]:105-114. doi: 10.24248/EAHRJ-D-19-00006. Epub 2019 Nov 29. PMID: 34308203; PMCID: PMC8279286.\u003c/li\u003e\n\u003cli\u003eMoodley J, Constant D, Mwaka AD, Scott SE, Walter FM [2020] Mapping awareness of breast and cervical cancer risk factors, symptoms and lay beliefs in Uganda and South Africa. PLoS ONE 15[10]: e0240788. https://doi.org/10.1371/journal.pone.0240788\u003c/li\u003e\n\u003cli\u003eYimer NB, Mohammed MA, Solomon K, Tadese M, Grutzmacher S, Meikena HK, et al.,. Cervical cancer screening uptake in Sub-Saharan Africa: a systematic review and meta-analysis. Public Health. 2021 Jun;195:105-111. doi: 10.1016/j.puhe.2021.04.014. Epub 2021 May 31. PMID: 34082174.\u003c/li\u003e\n\u003cli\u003eLott, B.E., Trejo, M.J., Baum, C. et al. Interventions to increase uptake of cervical screening in sub-Saharan Africa: a scoping review using the integrated behavioral model. BMC Public Health 20, 654 (2020). https://doi.org/10.1186/s12889-020-08777-4\u003c/li\u003e\n\u003cli\u003eChigbu CO, Onyebuchi AK, Onyeka TC, Odugu BU, Dim CC. The impact of community health educators on uptake of cervical and breast cancer prevention services in Nigeria. Int J Gynaecol Obstet. 2017;137(3):319\u0026ndash;24.\u003c/li\u003e\n\u003cli\u003eMbachu C, Dim C, Ezeoke U. Effects of peer health education on perception and practice of screening for cervical cancer among urban residential women in south-East Nigeria: a before and after study. BMC Womens Health. 2017;17(1):41.\u003c/li\u003e\n\u003cli\u003eMontano DE, Kasprzyk D. Theory of reasoned action, theory of planned behaviour, and the integrated behavioural model. Health Behaviour. 2015; 70(4):231. \u003c/li\u003e\n\u003cli\u003eNdikom CM, Ofi BA, Omokhodion FO, Adedokun BO. Effects of educational intervention on women\u0026rsquo;s knowledge and uptake of cervical cancer screening in selected hospitals in Ibadan, Nigeria. Int J Health Promot Educ. 2017;55(5\u0026ndash;6):259\u0026ndash;71.\u003c/li\u003e\n\u003cli\u003eWHO fact sheet: Cervical cancer 17\u003csup\u003eth\u003c/sup\u003e November 2023. \u003c/li\u003e\n\u003cli\u003eOkyere J, Aboagye RG, Seidu AA, Asare BY, Mwamba B, Ahinkorah BO. Towards a cervical cancer-free future: women\u0026apos;s healthcare decision making and cervical cancer screening uptake in sub-Saharan Africa. BMJ Open. 2022 Jul 29;12(7):e058026. doi: 10.1136/bmjopen-2021-058026. PMID: 35906053; PMCID: PMC9345091.\u003c/li\u003e\n\u003cli\u003eGlenn WJ, Matovu, JKB, Juncker, M; Namisango, E, Bouskill, K; Nakami, S, et al. Correlates of cervical cancer prevention advocacy and cervical cancer screening in Uganda: Cross-sectional evaluation of a conceptual model. Medicine 102[34]:p e34888, August 25, 2023. | DOI: 10.1097/MD.0000000000034888 \u003c/li\u003e\n\u003cli\u003eMoses E, Pedersen HN, Mitchell SM, Sekikubo M, Mwesigwa D, Singer J, Biryabarema C, Byamugisha JK, Money DM, Ogilvie GS. Uptake of community-based, self-collected HPV testing vs. visual inspection with acetic acid for cervical cancer screening in Kampala, Uganda: preliminary results of a randomised controlled trial. Trop Med Int Health. 2015 Oct;20(10):1355-67. doi: 10.1111/tmi.12549. Epub 2015 Jun 28. PMID: 26031572.\u003c/li\u003e\n\u003cli\u003eRawat, A., Mithani, N., Sanders, C. \u003cem\u003eet al.\u003c/em\u003e \u0026ldquo;We Shall Tell them with Love, Inform them what we have Learnt and then Allow them to go\u0026rdquo; - Men\u0026rsquo;s Perspectives of Self-Collected Cervical Cancer Screening in Rural Uganda: A Qualitative Inquiry. \u003cem\u003eJ Canc Educ\u003c/em\u003e \u003cstrong\u003e38\u003c/strong\u003e, 618\u0026ndash;624 [2023]. https://doi.org/10.1007/s13187-022-02163-x\u003c/li\u003e\n\u003cli\u003eMutyaba T, Mirembe F, Sandin S, Weiderpass E. Male partner involvement in reducing loss to follow-up after cervical cancer screening in Uganda. IntJGynaecolObstet. 2009; 107[2]:103\u0026ndash;6. https://doi.org/10. 1016/j.ijgo.2009.07.019 PMID: 19716557.\u003c/li\u003e\n\u003cli\u003eOkeke EN, Adepiti CA, Ajenifuja KO. What is the price of prevention? New evidence from a field experiment. J Health Econ. 2013;32(1):207\u0026ndash;18.\u003c/li\u003e\n\u003cli\u003eBirhanu, Z., Abdissa, A., Belachew, T. \u003cem\u003eet al.\u003c/em\u003e Health seeking behavior for cervical cancer in Ethiopia: a qualitative study. \u003cem\u003eInt J Equity Health\u003c/em\u003e \u003cstrong\u003e11\u003c/strong\u003e, 83 [2012]. https://doi.org/10.1186/1475-9276-11-83\u003c/li\u003e\n\u003cli\u003eAbiodun OA, Olu-Abiodun OO, Sotunsa JO, Oluwole FA. Impact of health education intervention on knowledge and perception of cervical cancer and cervical screening uptake among adult women in rural communities in Nigeria. BMC Public Health. 2014;14:814.\u003c/li\u003e\n\u003cli\u003eGottschlich, A., Payne, B.A., Trawin, J. et al. Community-integrated self-collected HPV-based cervix screening in a low-resource rural setting: a pragmatic, cluster-randomized trial. Nat Med 29, 927\u0026ndash;935 (2023). https://doi.org/10.1038/s41591-023-02288-6.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Risk factors, symptoms, intended behaviour, cervical cancer screening","lastPublishedDoi":"10.21203/rs.3.rs-3849445/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3849445/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKnowledge of risk factors and symptoms of cervical cancer has been found to promote uptake of screening of cervical cancer. Most interventions targeted women without much involvement of men (husbands) who are often decision makers in many low- and middle-income countries. This study aimed at assessing baseline knowledge and intended behaviour of both women and men to enable design specific targeted messages to increase uptake of cervical cancer screening and promote early detection of women with symptoms.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted in two districts in Western Uganda using the modified African Women Awareness of CANcer (AWACAN) questionnaire. Women aged 30–49 years and their husbands/decision makers were interviewed. Knowledge on risk factors and symptoms, intended behaviour and barriers towards participation in cervical cancer screening and treatment were assessed. Descriptive and logistic regression analyses were done to establish the association between knowledge levels and other factors comparing women to men.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 724 women and 692 men were enrolled. Of these, 71.0% women and 67.2% men had ever heard of cervical cancer and 8.8% women had ever been screened. Knowledge of risk factors and symptoms of cervical cancer was high and similar for both women and men.\u003c/p\u003e\n\u003cp\u003eLack of decision making by women was associated with low knowledge of risk factors (X\u003csup\u003e2 \u003c/sup\u003e= 14.542; p = 0.01), low education (X\u003csup\u003e2\u003c/sup\u003e = 36.05, p \u0026lt; 0.01) and older age (x\u003csup\u003e2 \u003c/sup\u003e= 17.33, p \u0026lt; 0.01).\u0026nbsp; Men had better help seeking behaviour than women (X\u003csup\u003e2\u003c/sup\u003e = 64.96, p \u0026lt; 0.01, OR = 0.39, 95% CI: 0.31 - 0.50) and were more confident and skilled in recognising a sign or symptom of cervical cancer (X\u003csup\u003e2\u003c/sup\u003e = 27.28, p \u0026lt; 0.01, OR = 0.52, CI (0.40 - 0.67).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe baseline knowledge for cervical cancer was high in majority of participants and similar in both women and men. Their intended behaviour towards screening was also positive but screening uptake was very low.\u0026nbsp; This study suggests developing messages on multiple interventions to promote screening behaviour in addition to education, consisting of male involvement, women empowerment and making services available, accessible and women friendly.\u003c/p\u003e","manuscriptTitle":"Baseline knowledge on risk factors, symptoms and intended behaviour of women and men towards screening and treatment of cervical cancer in rural Uganda: A cross-sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-02-07 16:56:30","doi":"10.21203/rs.3.rs-3849445/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-03-02T21:27:48+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-02-29T01:35:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"bb601cce-0f29-4ab1-adc5-877f07589dd9","date":"2024-02-16T10:27:39+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-02-16T10:23:48+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-02-05T07:59:09+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-02-03T02:09:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-02-03T02:09:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Cancer","date":"2024-01-10T04:27:03+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-cancer","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bcan","sideBox":"Learn more about [BMC Cancer](http://bmccancer.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bcan/default.aspx","title":"BMC Cancer","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0d359908-0fb4-409d-8c05-f9a862d31f26","owner":[],"postedDate":"February 7th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-04-15T15:05:15+00:00","versionOfRecord":{"articleIdentity":"rs-3849445","link":"https://doi.org/10.1186/s12885-024-12223-8","journal":{"identity":"bmc-cancer","isVorOnly":false,"title":"BMC Cancer"},"publishedOn":"2024-04-11 15:01:46","publishedOnDateReadable":"April 11th, 2024"},"versionCreatedAt":"2024-02-07 16:56:30","video":"","vorDoi":"10.1186/s12885-024-12223-8","vorDoiUrl":"https://doi.org/10.1186/s12885-024-12223-8","workflowStages":[]},"version":"v1","identity":"rs-3849445","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3849445","identity":"rs-3849445","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}