“Even with one Man, but with many women, you can get Cervical Cancer”: Qualitative exploration of Women’s Perceptions and Experienced barriers to cervical cancer screening in Uganda

“Even with one Man, but with many women, you can get Cervical Cancer”: Qualitative exploration of Women’s Perceptions and Experienced barriers to cervical cancer screening in Uganda | 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 “Even with one Man, but with many women, you can get Cervical Cancer”: Qualitative exploration of Women’s Perceptions and Experienced barriers to cervical cancer screening in Uganda Robert M. Bulamba, Fred Nalugoda, Amanda P. Miller, Alex Daama, and 14 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7603002/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Cervical cancer is a leading cause of cancer-related morbidity and mortality among women in low-resource settings. Despite the availability of screening services in Uganda, uptake remains unacceptably low. Objectives To explore perceptions, attitudes, knowledge, and barriers to cervical cancer screening among women aged 25 to 65 years in the urban and rural areas of Wakiso District, Uganda. Design and setting: We conducted focus group discussions (FGDs) and key informant interviews (KIIs) in the urban and rural communities within Wakiso District, Central Uganda. Participants: Six focus group discussions (three in rural and three in urban) with sixty women aged between 25–65 years and four key informant interviews with healthcare workers and administrators. Results Knowledge levels varied regarding cervical cancer risk factors, causes, signs, symptoms, and prevention. FGD participants linked cervical cancer to risky sexual behaviors, particularly involving multiple sexual partners or sexual intercourse with uncircumcised men, while some key informants said that some women believed that the disease was due to witchcraft. Concerns were also raised about family planning methods such as IUDs and pills, which some participants believed to cause cervical cancer. Poor hygiene practices, including the use of unclean public toilets and poor menstrual hygiene, were also seen as risk factors. Myths and misconceptions about cervical cancer screening, such as fears of removal of the cervix during screening, were prevalent. Although some women had positive experiences with screening, concerns about pain, discomfort, and limited privacy during screening were commonly reported. Conclusion While knowledge of cervical cancer exists among women in Wakiso District, significant misconceptions, fears, and systemic barriers impede screening uptake. Culturally sensitive health education and accessible, respectful screening services are critical to improving participation. Introduction Cervical cancer is a deadly but preventable disease that disproportionately affects women in low- and middle-income countries (LMICs), accounting for more than 85% of global cervical cancer deaths ( 1 ) . In Uganda, cervical cancer is the leading cause of cancer-related deaths among women, with approximately 7000 new cases and more than 4,600 deaths annually ( 2 ) . Despite being preventable through timely screening and early treatment, cervical cancer continues to claim the lives of thousands of women annually due to limited access and poor utilization of preventive services ( 3 ) . The Ugandan Ministry of Health (MoH), in partnership with international partners, has introduced several interventions, including the integration of visual inspection with acetic acid (VIA) into routine reproductive health services and the rollout of Human Papillomavirus (HPV) vaccination among school-aged girls ( 4 ) . While these initiatives are commendable, implementation remains inconsistent, and national coverage of cervical cancer screening is estimated to be less than 30% (5) . This indicates that barriers beyond just service availability are impeding uptake. One major challenge is the ongoing gap in knowledge and awareness about cervical cancer in the community. Several studies have shown that many women, particularly in rural and peri-urban areas, are unaware of the risk factors, symptoms, and benefits of early detection ( 6 )( 7 ) . Misconceptions are common, including beliefs that cervical cancer is caused by prolonged contraceptive use, poor hygiene, or witchcraft ( 8 ) . These beliefs are often influenced by informal social networks, peer discussions, and misinformation, which can discourage women from accessing screening services. Additionally, sociocultural factors play a significant role in women's health-seeking behaviors. In many Ugandan communities, gender norms and expectations influence access to reproductive health care. Women often need spousal permission to seek care, and disapproval from male partners is identified as a major barrier to cervical cancer screening ( 9 ) . In some cases, screening is linked to promiscuity, further reducing its acceptance among women. Health system barriers such as long waiting times, inadequately trained personnel, stockouts of essential supplies, insufficient privacy during examinations, and poor healthcare workers’ attitudes also persist ( 10 ) . Women reported feeling disrespected or judged by health care personnel when attempting to access reproductive health services, which undermines trust and discourages follow-up visits ( 11 ) . Additionally, despite the availability of cervical cancer screening in some areas, the cost of related services and accessibility serve as barriers for many, particularly in underserved areas. While quantitative studies have documented low screening rates, they often fail to explain the underlying reasons for this trend ( 12 ) . A qualitative approach allows for a deeper exploration of women’s beliefs, fears, and motivations, capturing the nuanced interplay between individual, interpersonal, and systemic factors. Unfortunately, there is limited qualitative population-level data on women’s lived experiences and perceptions about cervical cancer prevention within Wakiso district. The knowledge gap this study aimed to address lay in the limited understanding of how women interpret cervical cancer-related messages and how this influences their decision to utilize screening services. The study also sought to amplify the voices of women and healthcare providers, offering a platform for their insights to inform future interventions. The study adopts a holistic lens to examine the challenges and opportunities for increasing cervical cancer screening uptake in Uganda. By generating context-specific evidence from Wakiso District, the findings inform culturally sensitive, community-driven interventions to enhance cervical cancer prevention and control in Uganda, and contribute to national and global efforts aimed at eliminating cervical cancer as a public health threat by 2030 ( 4 ) . Methods Study area, design, and population The study was conducted in Wakiso, the most populous district in Uganda, with a population of 3.4 million people ( 13 ) , and the majority are women (51%), occupying approximately 1,884Km 2( 14 ) . The major economic activities in the district include subsistence and commercial agriculture, fishing, and the operation of small and large trading and vending businesses in trading centres. The study utilized focus group discussions (FGDs) with women aged 25 to 65 years who had lived in the study district for a minimum of six months. This age group was chosen because of their eligibility for cervical cancer screening services, have a higher risk for cervical cancer, and are targeted by the national programs for cervical cancer prevention in Uganda ( 15 ) . Key informant interviews (KIIs) were also conducted with members of the district health teams, including the district health officer and healthcare workers in both private and public healthcare facilities at different levels, such as nurses, medical officers, gynecologists, clinical officers, and midwives. Sampling This study was nested within the Africa Medical and Behavioral Sciences Organization (AMBSO) Population Health Surveillance (APHS) Cohort study framework. The cohort profile has been described elsewhere ( 16 ) . Briefly, the APHS is an open longitudinal population-based cohort study established in 2018. The APHS is the first health and demographic surveillance system (HDSS) in Uganda to include urban sites in addition to semi-urban, rural, and fishing communities, and tracks health outcomes and their determinants in diverse communities. APHS focuses on under-researched and emerging public health issues in Uganda, including mental health, substance use, gender-based violence (GBV), violence against children, food insecurity, health behaviors, disability, and emerging diseases. Data collection from census activities and surveys target community types that exhibit considerable variation in risk behaviors and health conditions. As such, the cohort reflects the diversity of the Ugandan population and allows for stratification by district and community type. The communities were selected to ensure a wide geographical coverage of the study area as well as to represent subpopulations of women in terms of rural-urban residence and socioeconomic status. Our qualitative study leveraged two of the three Wakiso communities of APHS. We conducted three FGDs in each communities, making a total of six FGDs. The local leaders and the village health teams (VHTs, similar to community health workers) in the selected communities guided the identification and purposive recruitment of women participants eligible for interviews. The participants were then approached and invited to participate in the FGDs. The participants for the KIIs were purposively selected based on their technical knowledge and involvement in decision-making relating to the provision of cervical cancer screening services in the district. Four (4) KIIs were conducted in the two communities, and the numbers in both the FGDs and KIIs satisfied theoretical saturation ( 17 ) , when no new ideas were emerging from participants. Data Collection We developed thematic guides for both the FGDs and KIIs based on previous literature ( 18 )( 11 )( 19 ) and pretested them among a similar study population (n = 4), before finalizing tools for data collection.. Data collection was conducted over one week, from 25th September to 2nd October 2024. The FGD guide explored knowledge about cervical cancer and screening, attitudes, perceptions, barriers to participation, and strategies to improve women’s participation in cervical cancer screening services. The KII guide included questions on community perception and knowledge about cervical cancer and screening, health system capacity to perform cervical cancer screening, and opinions on measures to increase the utilization of screening services. The guides had probes and prompts to guide the research assistants during data collection. On average, each FGD comprised of 10 participants. FGDs were conducted by four (4) trained research assistants who are native Luganda speakers with vast experience conducting qualitative research. Each interview session was conducted by two (2) research assistants, one of whom moderated and facilitated the discussion, while the other took notes and recorded the interviews. The FGDs were conducted in places identified by the research team in coordination with the local leaders and VHTs. Interview venues were carefully selected to ensure privacy, and all participants were encouraged to openly discuss their opinions. FGDs lasted for about 40–45 minutes, excluding 5–10 minutes for the informed consent process and rapport creation.. For the KIIs, when every key informant was identified, the research team scheduled appointments by phone, and interviews were conducted at time and place most convenient to the participant (most preferred their workplaces). KIIs lasted for about 30–35 minutes. All interviews were audio-recorded. Data Management and Analysis The audio-labelled FGD recordings were transcribed verbatim from the local language (Luganda) to English and proofread several times by research assistants. The transcripts were reviewed and emerging themes noted. All the researchers, RN (clinical nurse), EM (social scientist), JN (social scientist), and RB (Public health specialist) have experience in designing and conducting qualitative research. Three (3) of the researchers (EM, JN, and RB) are males, while RN is a female. Two researchers (EM and RB) independently developed the codebook for data analysis and described the coding tree, which was then reviewed and discussed with other researchers, and any differences were harmonized. Data was interpreted, coded, and then analyzed using content analysis with the help of NVivo qualitative data management software. Direct quotations are presented in italics to highlight and support key findings. The consolidated Criteria for Reporting Qualitative Research (COREQ-32) checklist ( 20 ) guided the reporting of our results in this study. Ethical Considerations The study was reviewed and approved by the Clark International University– Research Ethics Committee (CIU-REC) and registered with the Uganda National Council for Science and Technology (UNCST). Written informed consent was voluntarily obtained from all study participants after the moderator or interviewer explained all the study aims, benefits, and potential risks in participating in this study, in accordance with the Declaration of Helsinki standard. The anonymity of participants was diligently maintained throughout the research process by the use of numbers and treating the data with confidentiality. Results Sociodemographic characteristics of the study participants Of the 60 women who participated in the FGDs, median age was 38 years (IQR = 31–46 years), and most (38%) were 25–35 years old a (see Table 1 ). Majority (53%) were living in the urban area, married (63%), were involved in self-employment (business work), and were Catholic (47%). Nearly half had attained a secondary level education (48%). Table 1 Socio-demographic characteristics of the FGD study participants Characteristics Frequency (n = 60) Proportion (%) Community Setting Rural 28 47% Urban 32 53% Age (Years) , Median age = 38 years, IQR = 31–46 years 25–35 23 38% 36–45 21 35% 46–65 16 27% Marital Married 38 63% Not married 17 28% Widowed 5 8% Education Level No education 2 3% Primary 26 43% Secondary and above 32 53% Employment Type Business women 36 60% Farmer 11 18% Hair dresser 5 8% Casual worker 3 13% Religion Anglicans 14 23% Catholics 28 47% Muslims 12 20% Others 6 10% Other employment includes : Healthcare work, casual workers, Housework in their own home, and None. Other Religion includes : Faith of Unity, Saved. Born again, Seventh Day Adventists, and None. Knowledge and perceptions of cervical cancer and cervical cancer screening Knowledge of cervical cancer and its screening was widespread among participants, although often shaped by myths and misconceptions. Many women demonstrated awareness that cervical cancer is primarily sexually transmitted, commonly linking it to men’s risky sexual behaviors, especially adultery and poor genital hygiene. Participants perceived that having multiple sexual partners, intercourse with uncircumcised men, engaging in sex during menstruation, or shortly after childbirth were major risk factors of cervical cancer. Some believed that even one’s monogamy could not protect them if their partner had unprotected sex with others: “Doctor, what I know, even if you have only one man, but he has another woman, you can get cervical cancer through him” [FGD Participant, aged 25–35 years]. Misconceptions included beliefs that family planning methods, especially the intrauterine device (IUD), cause cervical cancer disease, liking its long-term use to rusting metal in the body. “I heard from my friends where I stay that the family planning methods we use especially IUD causes cervical cancer. They even gave me an example that if a metal can rust when placed on a mere substance, how dangerous could it be in the human body?” [FGD Participant, aged 36–45 years]. Additionally, some women thought that halting menstruation using medication or engaging in sex during menstrual periods caused "blood clots" that could trigger cancer. “For me I think, for the women who get into their menstruation period, then they use medicines that stops the blood from flowing yet the blood is meant to flow. Each time you prevent the blood from flowing out it creates blood clots, leading to cancer of the cervix” [FGD Participant, aged 36–45 years]. Despite these misconceptions, some participants had undergone cervical cancer screening. Experiences varied: some found it painless and straightforward, while others described discomfort, embarrassment, and fear, and invasive procedures that they underwent. Notably, many women believed that the cervix is removed during screening, a misconception and mix-up between screening and treatment through conization that deterred others from participating. “For the others they say, the cervix is usually removed and put on plate or extracted and it is put aside. What they heard is what they usually pick up so you try as much as you can to explain the whole procedure on how it is done, they end saying you can go, me for one am not going anywhere” [FGD Participant, aged 46–65 years]. Barriers to Cervical Cancer Screening Cultural and Social Barriers Numerous barriers were identified and categorized into sociocultural, informational, structural, and psychological factors. Culturally, some participants held beliefs that cervical cancer was caused by witchcraft or was incurable, discouraging them from seeking medical interventions. Others believed that circumcision among Muslim husbands protected women, which reduced perceived susceptibility. “The other thing a woman could say after all my husband is Muslem since they are circumcised and hence, they are never dirty after all where will he have gotten the cancer that eats up the cervix, so because of that belief they would choose to stick to that instead.” [FGD Participant, aged 25–35 years] Embarrassment and shyness also played a substantial role, especially among older women who expressed discomfort with exposing themselves to young or male health workers: “I can’t open up like that in front of someone of my daughter’s age” [FGD Participant aged 46–65 years]. “For me what I think that stops people from going for screening, for example I have seen a scenario where women run away from the queue at the health facility this is because some of these facilities use student doctors. For instance a women who is about 50 years cannot allow a young doctor examine them because they consider them their children thus leads up a situation where some leave the queue. Another thing is women are afraid of men examining them especially with the older years” [FGD Participant, aged 46–65 years] Similarly, social rumors and lack of confidentiality discouraged participation, and some think it can lead to death once screened. Participants reported undignified screening procedures, including lack of privacy and inappropriate comments from healthcare workers, were common deterrents. “Some women get scared to go for cervical cancer screening especially when they get reports from other people that have been screened. There is a case of a woman who went for the screening but after the test she became even worse until she died. So when someone hears such they decide not to go for the test so people have different perceptions but they are mainly based on what they hear from those that go for the test. Others wait when they get so ill” [FGD Participant, aged 46–65 years] Gender Dynamics and Power Relations A recurring theme was the influence of male partners on women’s healthcare decisions. Many participants reported that their husbands either discouraged or outright prohibited them from attending screening services, citing jealousy or suspicion of infidelity. “If you tell him you want to screen, he asks, ‘Where did you get the disease?” [FGD Participant aged 46–65 years]. Women described how patriarchal norms within their households, often led them to avoid the service altogether to maintain domestic peace. “… I for one think some women are being stopped to go for screening for cervical cancer by their husbands, some men tend to be tough on the women and they condemn them for leaving home to go take part in screening services I would think it is an obstacle for some women.” [FGD Participant aged 36–45 years] This was also noted among the key informants that male disapproval significantly influenced women’s decision to seek the screening services: “Some men refuse to allow their wives to screen. They think if she’s found with cancer, it means he’s cheating” [KII_001]. Additionally, vulnerable women experiencing domestic violence or economic dependence were unable to make independent decisions regarding their health. Others were limited by their roles at home, particularly mothers without childcare support. “They cannot leave their children or house chores to go for screening” [KII_002]. Health System-Related Barriers Women described how systemic barriers such as long wait times, understaffing, lack of equipment, inconsistence in service delivery, and charging for the services discourage women from seeking screening services. Additionally, women in Uganda often face unexpected charges for cervical cancer screenings due to corruption, despite services being advertised as free of charge. This financial unpredictability discourages many from seeking essential screenings, especially those with limited resources. Several women reported being told to return later due to absent staff or being asked to purchase gloves or other supplies, despite services being advertised as free. “The health workers always advise us to go there that the services are free of charge but when you reach there, the healthcare providers tell you to pay some money. So a woman may come from here knowing that the service is free of charge [inaudible voices in the background] and she carries only her transport but upon reaching there, they are told by health workers that the free things ended” [FGD Participant, aged 36–45 years]. Additionally, the presence of only one screening device in some health centers led to extended waiting periods, deterring women who were balancing other domestic or work responsibilities. Privacy concerns, especially during mass screening events where multiple women were examined in the same room, further discouraged attendance. “When we went for that checkup, it was like an emergency, the health workers were putting four women in a room so there was an instance where they told an old lady to put off her clothes and the health workers realized she did not have an underwear so one of them shouted “you don’t even have an underwear?” so she felt ashamed” [FGD Participant aged 46–65 years] Most informants acknowledged that the screening procedure is perceived as uncomfortable and invasive, often deterring women from participation. One provider explained, “It is very uncomfortable for women. You expose the most private parts, and this makes them uneasy… The position we put them in and ‘okwegaala’ [opening their legs widely] makes them very uncomfortable” [KII_003]. Frequent stockouts of essential supplies such as acetic acid, insufficient staffing, and inadequate space for private examinations at healthcare facilities were cited as major issues hindering screening of women for cervical cancer. “We get people after mobilizing, but then the materials get finished. Even the nurse becomes demoralized” [KII_001]. Knowledge Gaps and Misinformation Participants frequently cited inadequate health education and persistent misinformation as significant obstacles. Some women were unsure of the symptoms of cervical cancer, leading them to believe that the absence of pain itself meant absence of disease. “If I’m not feeling sick, why should I be screened?” [FGD Participant aged 36–45 years]. Health workers were criticized for not explaining the screening process or the disease in detail, contributing to knowledge gaps. “We the women are not so much aware about cervical cancer and therefore, we are not aware of its signs and symptoms [all participants repeat the same word] “we do not know them”. Such as, when I have this, it’s a sign that I could be having cervical cancer. So it requires these health officers to continuously sensitize us because when we visit the health centers they just keep on advising us to do cervical cancer screening but they don’t tell us” [FGD Participant aged 36–45 years] Myths around cervical cancer screening being painful or dangerous such as the belief that the procedure damages the cervix or involves unnecessary exposure were also prevalent. These misconceptions were often perpetuated by peers and, in some cases, even healthcare providers who failed to clarify doubts. Some women were reported to avoid screening for fear of pain or potential physical harm, while others feared being diagnosed with cancer itself. “There is a myth that when you’re screened for cancer of the cervix, you will be found with it. So many people avoid it” [KII_004]. Key informants noted that many women were unaware of the benefits of early detection and associated screening. As one stated, “Some women think the government wants to kill them. They say things that are weird… they think it’s something bad disguised as good” [KII_001]. Additionally, the HPV vaccine is misunderstood and feared, with some believing it causes infertility or cancer: “They say that vaccinating children with the injection will prevent them from giving birth” [KII_002]. Motivators and facilitators to cervical cancer Screening Despite the barriers, several enabling factors were reported. Community sensitization and health education sessions especially those conducted by Village Health Teams (VHTs) and local health workers emerged as powerful motivators. Some participants appreciated being educated during routine visits or community outreach events, which made them more willing to engage in screening. “When health workers talk to us, we get the courage to screen” [FGD Participant aged 46–65 years]. Positive interpersonal interactions with healthcare workers also influenced uptake. Women described that “If the health worker is kind, we open up and get screened” . For some participants, peer influence encouraged screening. Seeing their friends undergo screening without complications or witnessing someone recover from cervical cancer after early detection, reassured many women that the disease was manageable if discovered early. Participants mentioned that women can advocate for cervical cancer screening by employing a strategy of sharing real-life experiences and encouraging others to seek the service. Additionally, personal testimonies from those diagnosed and treated can motivate more women to get screened. “We can also try to show other fellow women how best to seek for the service and encourage them to seek the service bygiving live examples to them such that incase one has been screened and found with it they can say they were screened and also started their treatment; this would force others to also get to know where they stand in this case”. [FGD Participant aged 36–45 years]. Conversely, witnessing death from cervical cancer strongly influenced others to seek screening, particularly when the deceased was a known peer or community member “Doctor, what influenced me the most to go for cervical cancer screening was after I saw someone who died of it. That is when I decided to also go for the screening and see where I stand.” [FGD Participant aged 25–35 years] “What motivated [me] to be screened was the death of a friend. She was operated on and even they removed her cervix. So I make sure every August I go for screening”. [FGD Participant aged 46–65 years]. Key informants noted that integration of screening into existing healthcare services such as HIV care and family planning as an important strategy to increase uptake of cervical cancer screening. Additionally, community-based education, drama, radio campaigns, and testimonies from cervical cancer survivors were also cited as effective strategies. “When survivors come back and talk, they recruit many other women to test” [KII_003]. Accessibility of services also played a role. The presence of nearby health centers and the possibility of walking or using low-cost transport (boda bodas) reduced logistical burdens. Some women even opted to pay for private screening services to avoid long queues at government facilities, emphasizing the importance of service quality and efficiency. Supportive spouses were another key motivator. While many women lacked support from their husbands, those who did reported that encouragement from their partners made them more proactive about their health. While awareness and service availability have improved over the years, key informants emphasized the urgent need to scale up targeted education, community outreach, and health system support to dispel myths, reduce stigma, and ensure sustainable access to quality screening services. Suggested strategies for improving demand and uptake of cervical cancer screening services Participants offered numerous suggestions such as community-based sensitization: using megaphones, radio, and television to broadcast accurate information. Providing pre- and post counseling services to reduce anxiety and misinformation. Mandatory screening including cervical cancer screening into antenatal care, family planning and employment processes, Peer-led advocacy: Encouraging women who have been screened to share positive experiences. Health system reforms: Increasing staffing, ensuring availability of screening equipment, and maintaining patient confidentiality. As one participant summarized. “Let them educate us well and handle us kindly. If we know the truth and are treated well, we shall go for screening” . [FGD Participant aged 25–35 years]. Discussion This study offers critical insights into the socio-cultural, systemic, and interpersonal factors that influence cervical cancer screening behaviors among women in Wakiso District, Uganda. Through a qualitative exploration of focus group discussions and key informant interviews, the study revealed a complex web of knowledge gaps, fear, stigma, and health system challenges that collectively hinder uptake of screening services. These findings resonate not only with national studies in Uganda but also with broader evidence from Sub-Saharan Africa (SSA) and global contexts. The knowledge gaps observed in this study, particularly misconceptions around the causes of cervical cancer, are consistent with findings from other SSA countries. A prior review ( 21 ) found that myths about cervical cancer being caused by contraception, poor hygiene, or witchcraft were common across the region. In this study, similar misconceptions persisted, suggesting a critical need for targeted health education. These misbeliefs are not only inaccurate but dangerous, as they deter women from engaging in preventive behaviors like screening. Fear and fatalism further compound these knowledge gaps. Many participants believed that a diagnosis of cervical cancer equated to a death sentence. This perception is well documented in the literature. In South Africa, Moodley et al. (2019) reported that fear of positive results discouraged women from screening, even when services were available. In Uganda, similar themes have emerged, with fear of pain, embarrassment, and stigma all serving as barriers to screening ( 9 ) . These beliefs often stem from a lack of visible survivors and limited public discourse on successful treatment stories. This study’s findings highlight the strong influence of healthcare providers on cervical cancer screening services. In contexts where providers were respectful, communicative, and culturally sensitive, women expressed willingness to return and recommend services to peers. Conversely, negative experiences such as perceived rudeness, lack of privacy, or absence of female providers discouraged participation. This aligns with global evidence indicating that the quality of patient-provider interaction significantly affects screening uptake ( 22 ) . Training providers in compassionate care and ensuring gender-sensitive service delivery are essential components of successful screening programs. Another consistent theme across global and SSA literature is the role of peer and community influence. This study found that women were more likely to seek screening after hearing positive testimonies from friends or community members. Community-based mobilization, therefore, holds strong potential. Studies in Zambia and Nigeria have demonstrated that engaging community health workers and local champions can significantly increase awareness and service uptake ( 23 )( 18 ) . Uganda’s use of Village Health Teams (VHTs) offers a promising platform for scaling up such efforts. Gender dynamics also emerged as a powerful force shaping decision-making. In patriarchal settings, women often require permission from their husbands to access health services. Some participants in this study reported spousal resistance, with screening perceived as unnecessary or suspicious. This is a barrier echoed across SSA, where male involvement in reproductive health is often minimal. Programs in Kenya and Tanzania have begun involving men through couple-based health education, with promising outcomes in improving uptake and reducing gender-related stigma ( 24 ) . Systemic barriers including supply shortages, understaffing, and informal charges further limit access. Although cervical cancer screening is officially free in Uganda’s public health system, hidden costs such as buying gloves or transport fees disproportionately affect low-income women. Similar issues have been noted in Ethiopia and Ghana, where out-of-pocket expenses were major deterrents ( 25 )( 26 ) . Policymakers must ensure that funding mechanisms are in place to sustain service delivery and remove financial barriers. This study also highlighted the potential of integrating cervical cancer screening into other reproductive and maternal health services. Participants suggested offering screening during antenatal care (ANC) visits or immunization campaigns. Evidence from Rwanda and Malawi supports this integration approach, which has been shown to increase coverage without overwhelming existing systems ( 27 ) . In Uganda, where ANC attendance is relatively high, leveraging these touchpoints could significantly improve screening rates. From a policy perspective, the study supports the need for a multi-pronged, context-specific strategy. Educational campaigns must be localized, involve trusted community figures, and incorporate culturally relevant content. Health systems must prioritize respectful, confidential, and accessible service environments. Community engagement, particularly through testimonies from survivors and outreach by VHTs, is critical to reducing stigma and building trust. Importantly, this research provides evidence for rethinking national cervical cancer prevention strategies. Uganda’s National Strategic Plan (2020–2024) outlines goals for HPV vaccination, screening, and treatment. However, achieving these goals will require overcoming entrenched social and systemic obstacles, as documented in this study. Greater investment in community education, healthcare provider training, and mobile outreach services is essential. The study’s qualitative design enabled a rich, in-depth understanding of the factors influencing screening behavior. However, it also has limitations. The findings are context-specific and may not fully reflect the diversity of experiences across Uganda. Moreover, the perspectives of men and healthcare policymakers were not thoroughly explored. Future research could build on these findings through larger mixed-methods studies or intervention trials to test community-driven strategies. Conclusion Cervical cancer screening remains critically underused in Uganda and across SSA due to misinformation, fear, gender dynamics, and systemic issues. This study adds to growing evidence advocating for tailored, targeted, culturally sensistive, community-based, and system-strengthening interventions. Achieving the global goal of eliminating cervical cancer by 2030, as outlined by WHO, will require local actions based on the lived experiences of women like those in Wakiso District. Abbreviations WHO World Health Organization APHS AMBSO Population Health Surveillance SSA Sub-Saharan Africa ANC Antenatal Care VHT Village Health Teams IUD Intrauterine Device AMBSO Africa Medical and Behavioral Sciences Organization GBV Gender- Based Violence Declarations Ethics approval and consent to participate Ethical approval was obtained from Clark International University- Research Ethics Committee (CIU-REC), and the study was registered by the Uganda National Council for Science and Technology (UNCST). Participation in the study was voluntary, and participants provided written informed consent after they were explained to the details of the study, including the benefits and risks of participation, and the study adhered to the Declaration of Helsinki guidelines. Consent for publication Not applicable Availability of data and materials Data are available upon request from the corresponding author. Competing Interests The authors declare no competing interests. Funding Sincere appreciation goes to Wakiso District Local Government, the National Institute of Health and Care Research (NIHR) and the Royal School of Tropical Medicine and Hygiene (RSTMH) Early Careers Research Program for supporting the conduct of this research study. Authors' contributions RMB and GN conceived the study, contributed to its design, data collection and analysis and drafted the manuscript. RN, RN,JN, APM, WB, JBN, contributed in designing the study tools, data analysis and critical review of the manuscript. EK, SM, GK, FN, GKN, VN AD, AME, RN, EM, and SW, contributed to the review of the tools, research project administration and review of the manuscript. All authors read and approved the final manuscript. Acknowledgments The authors would like to thank the study participants for their time. We would also like to thank AMBSO’s research team for their tireless efforts during the field activities. 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Pilot Feasibility Stud [Internet]. 2022;8(1):1–7. Available from: https://doi.org/10.1186/s40814-022-01211-z Nakisige C, Schwartz M, Ndira AO. Cervical cancer screening and treatment in Uganda. Gynecol Oncol Reports [Internet]. 2017;20:37–40. Available from: http://dx.doi.org/10.1016/j.gore.2017.01.009 Mitchell EMK, Hall KM, Doede A, Rong A, McLean Estrada M, Granera OB, et al. Feasibility and acceptability of self-collection of Human Papillomavirus samples for primary cervical cancer screening on the Caribbean Coast of Nicaragua: A mixed-methods study. Front Oncol. 2023;12(January):1–9. UNFPA. The Journey towards Achieving Zero Unmet Need for Modern Family Planning: Re-evaluating Uganda’s efforts. 2020;(15):1–4. 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):1–15. Kauma G, Ddungu H, Ssewanyana I, Nyesiga S, Bogere N, Namulema-Diiro T et al. Virologic Nonsuppression Among Patients With HIV Newly Diagnosed With Cancer at Uganda Cancer Institute: A Cross-Sectional Study. JCO Glob Oncol. 2023;(9):1–10. Munnangi M, Lippus H, Gilyan R, Heidelberg U, Evans DP, Maxwell L. One’s life becomes even more miserable when we hear all those hurtful words. A mixed methods systematic review of disrespect and abuse in abortion care. 2023;(May). Available from: https://doi.org/10.21203/rs.3.rs-3710395/v1 Bulamba RM, Kyasanku E, Nalugoda F, Daama A, Nkale JM, Miller AP et al. Assessing Knowledge, Uptake and Factors associated with cervical cancer screening among women in selected communities of Wakiso District in Uganda: A population-based study. bioRxiv [Internet]. 2025;(10):2025.01.05.631384. Available from: https://www.biorxiv.org/content/10.1101/2025.01.05.631384v1%0 A https://www.biorxiv.org/content/ 10.1101/2025.01.05.631384v1.abstract Godoi FC, Prakash S, Bhandari BR. Final report Final report. Rev 3D Print potential red meat Appl [Internet]. 2021;1(23 February 2021):1–61. Available from: http://libdcms.nida.ac.th/thesis6/2010/b166706.pdf UBOS-Statistical Abstract. UGANDA BUREAU OF STATISTICS. 2020 Statistical Abstract. Uganda Bur Stat [Internet]. 2020;1:303. Available from: http://www.ubos.org/onlinefiles/uploads/ubos/pdfdocuments/abstracts/Statistical Abstract 2013.pdf. World Health Organization. Global strategy to accelerate the elimination of cervical cancer as a public health problem [Internet]. World Health Organization. 2020. 1–56 p. Available from: https://www.who.int/publications/i/item/9789240014107 Mugamba S, Ziegel L, Bulamba RM, Kyasanku E, Johansson Århem K, Sjöland CF, et al. Cohort Profile: The Africa Medical and Behavioral Sciences Organization (AMBSO) Population Health Surveillance (APHS) in rural, semi-urban and urban Uganda. Int J Epidemiol. 2023;52(2):E116–24. Fluminense UF, Afonso A, De, Nursing C. Theoretical saturation in qualitative research: an experience report in interview with schoolchildren. 2018;71(1):228–33. Ezechi OC, Ujah IO, Ostergren P-O, Petterson KO. O238 Willingness and Acceptability of Cervical Cancer Screening Among Hiv Positive Nigerian Women. Int J Gynecol Obstet [Internet]. 2012;119(S3):S344–5. Available from: http://dx.doi.org/10.1016/S0020-7292(12)60668-7 Ndejjo R, Mukama T, Kiguli J, Musoke D. Knowledge, facilitators and barriers to cervical cancer screening among women in Uganda: A qualitative study. BMJ Open. 2017;7(6):1–8. Tong A, Sainsbury P, Craig J. COREQ (Consolidated criteria for reporting qualitative research) checklist. Int J Qual Heal Care [Internet]. 2007;19(6):349–57. Available from: http://intqhc.oxfordjournals.org/content/19/6/349.abstract%0Ahttp://dx.doi.org/10.1093/intqhc/mzm042%0A https://www.ncbi.nlm.nih.gov/pubmed/17872937%0AAll Papers/T/Tong 2007 - Consolidated criteria for reporting qualitative research (COREQ) - a 32-i. Lim JNW, Ojo AA. Barriers to utilisation of cervical cancer screening in Sub Sahara Africa: a systematic review. Eur J Cancer Care (Engl). 2017;26(1). Chidyaonga-Maseko F, Chirwa ML, Muula AS. Underutilization of cervical cancer prevention services in low and middle income countries: A review of contributing factors. Pan Afr Med J. 2015;21:1–9. 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):1–8. Chigozie N. ASSESSMENT OF AN EDUCATIONAL INTERVENTION TO INCREASE Submitted in Partial Fulfillment of the Requirements. 2018. Adesegun OA, Binuyo T, Adeyemi O, Ehioghae O, Rabor DF, Amusan O, et al. The COVID-19 crisis in sub-saharan Africa: Knowledge, attitudes, and practices of the Nigerian public. Am J Trop Med Hyg. 2020;103(5):1997–2004. Tilahun M, Etifu M, Shewage T. Plant Diversity and Ethnoveterinary Practices of Ethiopia: A Systematic Review. Evidence-based Complement Altern Med. 2019;2019. Ngabo F, Franceschi S, Baussano I, Umulisa MC, Snijders PJF, Uyterlinde AM et al. Human papillomavirus infection in Rwanda at the moment of implementation of a national HPV vaccination programme. BMC Infect Dis [Internet]. 2016;16(1):1–10. Available from: http://dx.doi.org/10.1186/s12879-016-1539-6 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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17:25:39","extension":"html","order_by":4,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":108825,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7603002/v1/4fc653088835ecc937676cb7.html"},{"id":97240289,"identity":"e751f309-b363-44cd-9e68-29cc9e7f88d1","added_by":"auto","created_at":"2025-12-02 11:08:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":999747,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7603002/v1/a2be6f41-f366-466a-b9fe-ed6b5e29616b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"“Even with one Man, but with many women, you can get Cervical Cancer”: Qualitative exploration of Women’s Perceptions and Experienced barriers to cervical cancer screening in Uganda","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCervical cancer is a deadly but preventable disease that disproportionately affects women in low- and middle-income countries (LMICs), accounting for more than 85% of global cervical cancer deaths\u003csup\u003e(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/sup\u003e. In Uganda, cervical cancer is the leading cause of cancer-related deaths among women, with approximately 7000 new cases and more than 4,600 deaths annually\u003csup\u003e(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/sup\u003e. Despite being preventable through timely screening and early treatment, cervical cancer continues to claim the lives of thousands of women annually due to limited access and poor utilization of preventive services\u003csup\u003e(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e)\u003c/sup\u003e. The Ugandan Ministry of Health (MoH), in partnership with international partners, has introduced several interventions, including the integration of visual inspection with acetic acid (VIA) into routine reproductive health services and the rollout of Human Papillomavirus (HPV) vaccination among school-aged girls\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e. While these initiatives are commendable, implementation remains inconsistent, and national coverage of cervical cancer screening is estimated to be less than 30%\u003csup\u003e(5)\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis indicates that barriers beyond just service availability are impeding uptake. One major challenge is the ongoing gap in knowledge and awareness about cervical cancer in the community. Several studies have shown that many women, particularly in rural and peri-urban areas, are unaware of the risk factors, symptoms, and benefits of early detection\u003csup\u003e(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)\u003c/sup\u003e. Misconceptions are common, including beliefs that cervical cancer is caused by prolonged contraceptive use, poor hygiene, or witchcraft\u003csup\u003e(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/sup\u003e. These beliefs are often influenced by informal social networks, peer discussions, and misinformation, which can discourage women from accessing screening services. Additionally, sociocultural factors play a significant role in women's health-seeking behaviors. In many Ugandan communities, gender norms and expectations influence access to reproductive health care. Women often need spousal permission to seek care, and disapproval from male partners is identified as a major barrier to cervical cancer screening\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. In some cases, screening is linked to promiscuity, further reducing its acceptance among women.\u003c/p\u003e\u003cp\u003eHealth system barriers such as long waiting times, inadequately trained personnel, stockouts of essential supplies, insufficient privacy during examinations, and poor healthcare workers\u0026rsquo; attitudes also persist\u003csup\u003e(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e)\u003c/sup\u003e. Women reported feeling disrespected or judged by health care personnel when attempting to access reproductive health services, which undermines trust and discourages follow-up visits\u003csup\u003e(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/sup\u003e. Additionally, despite the availability of cervical cancer screening in some areas, the cost of related services and accessibility serve as barriers for many, particularly in underserved areas.\u003c/p\u003e\u003cp\u003eWhile quantitative studies have documented low screening rates, they often fail to explain the underlying reasons for this trend\u003csup\u003e(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/sup\u003e. A qualitative approach allows for a deeper exploration of women\u0026rsquo;s beliefs, fears, and motivations, capturing the nuanced interplay between individual, interpersonal, and systemic factors. Unfortunately, there is limited qualitative population-level data on women\u0026rsquo;s lived experiences and perceptions about cervical cancer prevention within Wakiso district. The knowledge gap this study aimed to address lay in the limited understanding of how women interpret cervical cancer-related messages and how this influences their decision to utilize screening services. The study also sought to amplify the voices of women and healthcare providers, offering a platform for their insights to inform future interventions. The study adopts a holistic lens to examine the challenges and opportunities for increasing cervical cancer screening uptake in Uganda. By generating context-specific evidence from Wakiso District, the findings inform culturally sensitive, community-driven interventions to enhance cervical cancer prevention and control in Uganda, and contribute to national and global efforts aimed at eliminating cervical cancer as a public health threat by 2030\u003csup\u003e(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy area, design, and population\u003c/h2\u003e\u003cp\u003eThe study was conducted in Wakiso, the most populous district in Uganda, with a population of 3.4\u0026nbsp;million people\u003csup\u003e(\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)\u003c/sup\u003e, and the majority are women (51%), occupying approximately 1,884Km\u003csup\u003e2(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e)\u003c/sup\u003e. The major economic activities in the district include subsistence and commercial agriculture, fishing, and the operation of small and large trading and vending businesses in trading centres. The study utilized focus group discussions (FGDs) with women aged 25 to 65 years who had lived in the study district for a minimum of six months. This age group was chosen because of their eligibility for cervical cancer screening services, have a higher risk for cervical cancer, and are targeted by the national programs for cervical cancer prevention in Uganda\u003csup\u003e(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e)\u003c/sup\u003e. Key informant interviews (KIIs) were also conducted with members of the district health teams, including the district health officer and healthcare workers in both private and public healthcare facilities at different levels, such as nurses, medical officers, gynecologists, clinical officers, and midwives.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eSampling\u003c/h3\u003e\n\u003cp\u003eThis study was nested within the Africa Medical and Behavioral Sciences Organization (AMBSO) Population Health Surveillance (APHS) Cohort study framework. The cohort profile has been described elsewhere\u003csup\u003e(\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e)\u003c/sup\u003e. Briefly, the APHS is an open longitudinal population-based cohort study established in 2018. The APHS is the first health and demographic surveillance system (HDSS) in Uganda to include urban sites in addition to semi-urban, rural, and fishing communities, and tracks health outcomes and their determinants in diverse communities. APHS focuses on under-researched and emerging public health issues in Uganda, including mental health, substance use, gender-based violence (GBV), violence against children, food insecurity, health behaviors, disability, and emerging diseases. Data collection from census activities and surveys target community types that exhibit considerable variation in risk behaviors and health conditions. As such, the cohort reflects the diversity of the Ugandan population and allows for stratification by district and community type. The communities were selected to ensure a wide geographical coverage of the study area as well as to represent subpopulations of women in terms of rural-urban residence and socioeconomic status. Our qualitative study leveraged two of the three Wakiso communities of APHS. We conducted three FGDs in each communities, making a total of six FGDs. The local leaders and the village health teams (VHTs, similar to community health workers) in the selected communities guided the identification and purposive recruitment of women participants eligible for interviews. The participants were then approached and invited to participate in the FGDs. The participants for the KIIs were purposively selected based on their technical knowledge and involvement in decision-making relating to the provision of cervical cancer screening services in the district. Four (4) KIIs were conducted in the two communities, and the numbers in both the FGDs and KIIs satisfied theoretical saturation\u003csup\u003e(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)\u003c/sup\u003e, when no new ideas were emerging from participants.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eWe developed thematic guides for both the FGDs and KIIs based on previous literature\u003csup\u003e(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/sup\u003e and pretested them among a similar study population (n\u0026thinsp;=\u0026thinsp;4), before finalizing tools for data collection.. Data collection was conducted over one week, from 25th September to 2nd October 2024. The FGD guide explored knowledge about cervical cancer and screening, attitudes, perceptions, barriers to participation, and strategies to improve women\u0026rsquo;s participation in cervical cancer screening services. The KII guide included questions on community perception and knowledge about cervical cancer and screening, health system capacity to perform cervical cancer screening, and opinions on measures to increase the utilization of screening services. The guides had probes and prompts to guide the research assistants during data collection. On average, each FGD comprised of 10 participants. FGDs were conducted by four (4) trained research assistants who are native Luganda speakers with vast experience conducting qualitative research. Each interview session was conducted by two (2) research assistants, one of whom moderated and facilitated the discussion, while the other took notes and recorded the interviews. The FGDs were conducted in places identified by the research team in coordination with the local leaders and VHTs. Interview venues were carefully selected to ensure privacy, and all participants were encouraged to openly discuss their opinions. FGDs lasted for about 40\u0026ndash;45 minutes, excluding 5\u0026ndash;10 minutes for the informed consent process and rapport creation.. For the KIIs, when every key informant was identified, the research team scheduled appointments by phone, and interviews were conducted at time and place most convenient to the participant (most preferred their workplaces). KIIs lasted for about 30\u0026ndash;35 minutes. All interviews were audio-recorded.\u003c/p\u003e\n\u003ch3\u003eData Management and Analysis\u003c/h3\u003e\n\u003cp\u003eThe audio-labelled FGD recordings were transcribed verbatim from the local language (Luganda) to English and proofread several times by research assistants. The transcripts were reviewed and emerging themes noted. All the researchers, RN (clinical nurse), EM (social scientist), JN (social scientist), and RB (Public health specialist) have experience in designing and conducting qualitative research. Three (3) of the researchers (EM, JN, and RB) are males, while RN is a female. Two researchers (EM and RB) independently developed the codebook for data analysis and described the coding tree, which was then reviewed and discussed with other researchers, and any differences were harmonized. Data was interpreted, coded, and then analyzed using content analysis with the help of NVivo qualitative data management software. Direct quotations are presented in italics to highlight and support key findings. The consolidated Criteria for Reporting Qualitative Research (COREQ-32) checklist\u003csup\u003e(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/sup\u003e guided the reporting of our results in this study.\u003c/p\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The study was reviewed and approved by the Clark International University\u0026ndash; Research Ethics Committee (CIU-REC) and registered with the Uganda National Council for Science and Technology (UNCST). Written informed consent was voluntarily obtained from all study participants after the moderator or interviewer explained all the study aims, benefits, and potential risks in participating in this study, in accordance with the Declaration of Helsinki standard. The anonymity of participants was diligently maintained throughout the research process by the use of numbers and treating the data with confidentiality.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003eSociodemographic characteristics of the study participants\u003c/h2\u003e\u003cp\u003eOf the 60 women who participated in the FGDs, median age was 38 years (IQR\u0026thinsp;=\u0026thinsp;31\u0026ndash;46 years), and most (38%) were 25\u0026ndash;35 years old a (see Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Majority (53%) were living in the urban area, married (63%), were involved in self-employment (business work), and were Catholic (47%). Nearly half had attained a secondary level education (48%).\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 the FGD study participants\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFrequency (n\u0026thinsp;=\u0026thinsp;60)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eProportion (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunity Setting\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eRural\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUrban\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge (Years)\u003c/b\u003e, Median age\u0026thinsp;=\u0026thinsp;38 years, IQR\u0026thinsp;=\u0026thinsp;31\u0026ndash;46 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e25\u0026ndash;35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e36\u0026ndash;45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e46\u0026ndash;65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMarital\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e63%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNot married\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWidowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo education\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e43%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSecondary and above\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eEmployment Type\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBusiness women\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e60%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFarmer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHair dresser\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCasual worker\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReligion\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnglicans\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCatholics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMuslims\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10%\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOther employment includes\u003c/b\u003e: Healthcare work, casual workers, Housework in their own home, and None. \u003cb\u003eOther Religion includes\u003c/b\u003e: Faith of Unity, Saved. Born again, Seventh Day Adventists, and None.\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\n\u003ch3\u003eKnowledge and perceptions of cervical cancer and cervical cancer screening\u003c/h3\u003e\n\u003cp\u003eKnowledge of cervical cancer and its screening was widespread among participants, although often shaped by myths and misconceptions. Many women demonstrated awareness that cervical cancer is primarily sexually transmitted, commonly linking it to men\u0026rsquo;s risky sexual behaviors, especially adultery and poor genital hygiene. Participants perceived that having multiple sexual partners, intercourse with uncircumcised men, engaging in sex during menstruation, or shortly after childbirth were major risk factors of cervical cancer. Some believed that even one\u0026rsquo;s monogamy could not protect them if their partner had unprotected sex with others:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctor, what I know, even if you have only one man, but he has another woman, you can get cervical cancer through him\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 25\u0026ndash;35 years].\u003c/p\u003e\u003cp\u003eMisconceptions included beliefs that family planning methods, especially the intrauterine device (IUD), cause cervical cancer disease, liking its long-term use to rusting metal in the body.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I heard from my friends where I stay that the family planning methods we use especially IUD causes cervical cancer. They even gave me an example that if a metal can rust when placed on a mere substance, how dangerous could it be in the human body?\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 36\u0026ndash;45 years].\u003c/p\u003e\u003cp\u003eAdditionally, some women thought that halting menstruation using medication or engaging in sex during menstrual periods caused \"blood clots\" that could trigger cancer.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For me I think, for the women who get into their menstruation period, then they use medicines that stops the blood from flowing yet the blood is meant to flow. Each time you prevent the blood from flowing out it creates blood clots, leading to cancer of the cervix\u0026rdquo;\u003c/em\u003e[FGD Participant, aged 36\u0026ndash;45 years].\u003c/p\u003e\u003cp\u003eDespite these misconceptions, some participants had undergone cervical cancer screening. Experiences varied: some found it painless and straightforward, while others described discomfort, embarrassment, and fear, and invasive procedures that they underwent. Notably, many women believed that the cervix is removed during screening, a misconception and mix-up between screening and treatment through conization that deterred others from participating.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;For the others they say, the cervix is usually removed and put on plate or extracted and it is put aside. What they heard is what they usually pick up so you try as much as you can to explain the whole procedure on how it is done, they end saying you can go, me for one am not going anywhere\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 46\u0026ndash;65 years].\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eBarriers to Cervical Cancer Screening\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eCultural and Social Barriers\u003c/h2\u003e\u003cp\u003eNumerous barriers were identified and categorized into sociocultural, informational, structural, and psychological factors. Culturally, some participants held beliefs that cervical cancer was caused by witchcraft or was incurable, discouraging them from seeking medical interventions. Others believed that circumcision among Muslim husbands protected women, which reduced perceived susceptibility.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The other thing a woman could say after all my husband is Muslem since they are circumcised and hence, they are never dirty after all where will he have gotten the cancer that eats up the cervix, so because of that belief they would choose to stick to that instead.\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 25\u0026ndash;35 years]\u003c/p\u003e\u003cp\u003eEmbarrassment and shyness also played a substantial role, especially among older women who expressed discomfort with exposing themselves to young or male health workers:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I can\u0026rsquo;t open up like that in front of someone of my daughter\u0026rsquo;s age\u0026rdquo;\u003c/em\u003e [FGD Participant aged 46\u0026ndash;65 years].\u003cem\u003e\u0026ldquo;For me what I think that stops people from going for screening, for example I have seen a scenario where women run away from the queue at the health facility this is because some of these facilities use student doctors. For instance a women who is about 50 years cannot allow a young doctor examine them because they consider them their children thus leads up a situation where some leave the queue. Another thing is women are afraid of men examining them especially with the older years\u0026rdquo;\u003c/em\u003e[FGD Participant, aged 46\u0026ndash;65 years]\u003c/p\u003e\u003cp\u003eSimilarly, social rumors and lack of confidentiality discouraged participation, and some think it can lead to death once screened. Participants reported undignified screening procedures, including lack of privacy and inappropriate comments from healthcare workers, were common deterrents.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some women get scared to go for cervical cancer screening especially when they get reports from other people that have been screened. There is a case of a woman who went for the screening but after the test she became even worse until she died. So when someone hears such they decide not to go for the test so people have different perceptions but they are mainly based on what they hear from those that go for the test. Others wait when they get so ill\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 46\u0026ndash;65 years]\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eGender Dynamics and Power Relations\u003c/h2\u003e\u003cp\u003eA recurring theme was the influence of male partners on women\u0026rsquo;s healthcare decisions. Many participants reported that their husbands either discouraged or outright prohibited them from attending screening services, citing jealousy or suspicion of infidelity.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If you tell him you want to screen, he asks, \u0026lsquo;Where did you get the disease?\u0026rdquo;\u003c/em\u003e [FGD Participant aged 46\u0026ndash;65 years].\u003c/p\u003e\u003cp\u003eWomen described how patriarchal norms within their households, often led them to avoid the service altogether to maintain domestic peace.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;\u0026hellip; I for one think some women are being stopped to go for screening for cervical cancer by their husbands, some men tend to be tough on the women and they condemn them for leaving home to go take part in screening services I would think it is an obstacle for some women.\u0026rdquo;\u003c/em\u003e [FGD Participant aged 36\u0026ndash;45 years]\u003c/p\u003e\u003cp\u003eThis was also noted among the key informants that male disapproval significantly influenced women\u0026rsquo;s decision to seek the screening services: \u003cem\u003e\u0026ldquo;Some men refuse to allow their wives to screen. They think if she\u0026rsquo;s found with cancer, it means he\u0026rsquo;s cheating\u0026rdquo;\u003c/em\u003e [KII_001].\u003c/p\u003e\u003cp\u003eAdditionally, vulnerable women experiencing domestic violence or economic dependence were unable to make independent decisions regarding their health. Others were limited by their roles at home, particularly mothers without childcare support.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They cannot leave their children or house chores to go for screening\u0026rdquo;\u003c/em\u003e [KII_002].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eHealth System-Related Barriers\u003c/h2\u003e\u003cp\u003eWomen described how systemic barriers such as long wait times, understaffing, lack of equipment, inconsistence in service delivery, and charging for the services discourage women from seeking screening services. Additionally, women in Uganda often face unexpected charges for cervical cancer screenings due to corruption, despite services being advertised as free of charge. This financial unpredictability discourages many from seeking essential screenings, especially those with limited resources. Several women reported being told to return later due to absent staff or being asked to purchase gloves or other supplies, despite services being advertised as free.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;The health workers always advise us to go there that the services are free of charge but when you reach there, the healthcare providers tell you to pay some money. So a woman may come from here knowing that the service is free of charge [inaudible voices in the background] and she carries only her transport but upon reaching there, they are told by health workers that the free things ended\u0026rdquo;\u003c/em\u003e [FGD Participant, aged 36\u0026ndash;45 years].\u003c/p\u003e\u003cp\u003eAdditionally, the presence of only one screening device in some health centers led to extended waiting periods, deterring women who were balancing other domestic or work responsibilities. Privacy concerns, especially during mass screening events where multiple women were examined in the same room, further discouraged attendance.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When we went for that checkup, it was like an emergency, the health workers were putting four women in a room so there was an instance where they told an old lady to put off her clothes and the health workers realized she did not have an underwear so one of them shouted \u0026ldquo;you don\u0026rsquo;t even have an underwear?\u0026rdquo; so she felt ashamed\u0026rdquo;\u003c/em\u003e [FGD Participant aged 46\u0026ndash;65 years]\u003c/p\u003e\u003cp\u003eMost informants acknowledged that the screening procedure is perceived as uncomfortable and invasive, often deterring women from participation. One provider explained,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is very uncomfortable for women. You expose the most private parts, and this makes them uneasy\u0026hellip; The position we put them in and \u0026lsquo;okwegaala\u0026rsquo; [opening their legs widely] makes them very uncomfortable\u0026rdquo;\u003c/em\u003e [KII_003].\u003c/p\u003e\u003cp\u003eFrequent stockouts of essential supplies such as acetic acid, insufficient staffing, and inadequate space for private examinations at healthcare facilities were cited as major issues hindering screening of women for cervical cancer.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We get people after mobilizing, but then the materials get finished. Even the nurse becomes demoralized\u0026rdquo;\u003c/em\u003e [KII_001].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eKnowledge Gaps and Misinformation\u003c/h2\u003e\u003cp\u003eParticipants frequently cited inadequate health education and persistent misinformation as significant obstacles. Some women were unsure of the symptoms of cervical cancer, leading them to believe that the absence of pain itself meant absence of disease.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;If I\u0026rsquo;m not feeling sick, why should I be screened?\u0026rdquo;\u003c/em\u003e [FGD Participant aged 36\u0026ndash;45 years].\u003c/p\u003e\u003cp\u003eHealth workers were criticized for not explaining the screening process or the disease in detail, contributing to knowledge gaps.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We the women are not so much aware about cervical cancer and therefore, we are not aware of its signs and symptoms [all participants repeat the same word] \u0026ldquo;we do not know them\u0026rdquo;. Such as, when I have this, it\u0026rsquo;s a sign that I could be having cervical cancer. So it requires these health officers to continuously sensitize us because when we visit the health centers they just keep on advising us to do cervical cancer screening but they don\u0026rsquo;t tell us\u0026rdquo;\u003c/em\u003e [FGD Participant aged 36\u0026ndash;45 years]\u003c/p\u003e\u003cp\u003eMyths around cervical cancer screening being painful or dangerous such as the belief that the procedure damages the cervix or involves unnecessary exposure were also prevalent. These misconceptions were often perpetuated by peers and, in some cases, even healthcare providers who failed to clarify doubts. Some women were reported to avoid screening for fear of pain or potential physical harm, while others feared being diagnosed with cancer itself.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;There is a myth that when you\u0026rsquo;re screened for cancer of the cervix, you will be found with it. So many people avoid it\u0026rdquo;\u003c/em\u003e [KII_004].\u003c/p\u003e\u003cp\u003eKey informants noted that many women were unaware of the benefits of early detection and associated screening. As one stated,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Some women think the government wants to kill them. They say things that are weird\u0026hellip; they think it\u0026rsquo;s something bad disguised as good\u0026rdquo;\u003c/em\u003e [KII_001].\u003c/p\u003e\u003cp\u003eAdditionally, the HPV vaccine is misunderstood and feared, with some believing it causes infertility or cancer:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;They say that vaccinating children with the injection will prevent them from giving birth\u0026rdquo;\u003c/em\u003e [KII_002].\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eMotivators and facilitators to cervical cancer Screening\u003c/h2\u003e\u003cp\u003eDespite the barriers, several enabling factors were reported. Community sensitization and health education sessions especially those conducted by Village Health Teams (VHTs) and local health workers emerged as powerful motivators. Some participants appreciated being educated during routine visits or community outreach events, which made them more willing to engage in screening.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When health workers talk to us, we get the courage to screen\u0026rdquo;\u003c/em\u003e [FGD Participant aged 46\u0026ndash;65 years].\u003c/p\u003e\u003cp\u003ePositive interpersonal interactions with healthcare workers also influenced uptake. Women described that \u003cem\u003e\u0026ldquo;If the health worker is kind, we open up and get screened\u0026rdquo;\u003c/em\u003e.\u003c/p\u003e\u003cp\u003eFor some participants, peer influence encouraged screening. Seeing their friends undergo screening without complications or witnessing someone recover from cervical cancer after early detection, reassured many women that the disease was manageable if discovered early. Participants mentioned that women can advocate for cervical cancer screening by employing a strategy of sharing real-life experiences and encouraging others to seek the service. Additionally, personal testimonies from those diagnosed and treated can motivate more women to get screened.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We can also try to show other fellow women how best to seek for the service and encourage them to seek the service bygiving live examples to them such that incase one has been screened and found with it they can say they were screened and also started their treatment; this would force others to also get to know where they stand in this case\u0026rdquo;.\u003c/em\u003e [FGD Participant aged 36\u0026ndash;45 years].\u003c/p\u003e\u003cp\u003eConversely, witnessing death from cervical cancer strongly influenced others to seek screening, particularly when the deceased was a known peer or community member\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Doctor, what influenced me the most to go for cervical cancer screening was after I saw someone who died of it. That is when I decided to also go for the screening and see where I stand.\u0026rdquo;\u003c/em\u003e [FGD Participant aged 25\u0026ndash;35 years]\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;What motivated [me] to be screened was the death of a friend. She was operated on and even they removed her cervix. So I make sure every August I go for screening\u0026rdquo;.\u003c/em\u003e [FGD Participant aged 46\u0026ndash;65 years].\u003c/p\u003e\u003cp\u003eKey informants noted that integration of screening into existing healthcare services such as HIV care and family planning as an important strategy to increase uptake of cervical cancer screening. Additionally, community-based education, drama, radio campaigns, and testimonies from cervical cancer survivors were also cited as effective strategies.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;When survivors come back and talk, they recruit many other women to test\u0026rdquo;\u003c/em\u003e [KII_003].\u003c/p\u003e\u003cp\u003eAccessibility of services also played a role. The presence of nearby health centers and the possibility of walking or using low-cost transport (boda bodas) reduced logistical burdens. Some women even opted to pay for private screening services to avoid long queues at government facilities, emphasizing the importance of service quality and efficiency. Supportive spouses were another key motivator. While many women lacked support from their husbands, those who did reported that encouragement from their partners made them more proactive about their health. While awareness and service availability have improved over the years, key informants emphasized the urgent need to scale up targeted education, community outreach, and health system support to dispel myths, reduce stigma, and ensure sustainable access to quality screening services.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eSuggested strategies for improving demand and uptake of cervical cancer screening services\u003c/h2\u003e\u003cp\u003e Participants offered numerous suggestions such as community-based sensitization: using megaphones, radio, and television to broadcast accurate information. Providing pre- and post counseling services to reduce anxiety and misinformation. Mandatory screening including cervical cancer screening into antenatal care, family planning and employment processes, Peer-led advocacy: Encouraging women who have been screened to share positive experiences. Health system reforms: Increasing staffing, ensuring availability of screening equipment, and maintaining patient confidentiality. As one participant summarized.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Let them educate us well and handle us kindly. If we know the truth and are treated well, we shall go for screening\u0026rdquo;\u003c/em\u003e. [FGD Participant aged 25\u0026ndash;35 years].\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers critical insights into the socio-cultural, systemic, and interpersonal factors that influence cervical cancer screening behaviors among women in Wakiso District, Uganda. Through a qualitative exploration of focus group discussions and key informant interviews, the study revealed a complex web of knowledge gaps, fear, stigma, and health system challenges that collectively hinder uptake of screening services. These findings resonate not only with national studies in Uganda but also with broader evidence from Sub-Saharan Africa (SSA) and global contexts.\u003c/p\u003e\u003cp\u003eThe knowledge gaps observed in this study, particularly misconceptions around the causes of cervical cancer, are consistent with findings from other SSA countries. A prior review\u003csup\u003e(\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e)\u003c/sup\u003e found that myths about cervical cancer being caused by contraception, poor hygiene, or witchcraft were common across the region. In this study, similar misconceptions persisted, suggesting a critical need for targeted health education. These misbeliefs are not only inaccurate but dangerous, as they deter women from engaging in preventive behaviors like screening. Fear and fatalism further compound these knowledge gaps. Many participants believed that a diagnosis of cervical cancer equated to a death sentence. This perception is well documented in the literature. In South Africa, Moodley et al. (2019) reported that fear of positive results discouraged women from screening, even when services were available. In Uganda, similar themes have emerged, with fear of pain, embarrassment, and stigma all serving as barriers to screening\u003csup\u003e(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/sup\u003e. These beliefs often stem from a lack of visible survivors and limited public discourse on successful treatment stories.\u003c/p\u003e\u003cp\u003eThis study\u0026rsquo;s findings highlight the strong influence of healthcare providers on cervical cancer screening services. In contexts where providers were respectful, communicative, and culturally sensitive, women expressed willingness to return and recommend services to peers. Conversely, negative experiences such as perceived rudeness, lack of privacy, or absence of female providers discouraged participation. This aligns with global evidence indicating that the quality of patient-provider interaction significantly affects screening uptake\u003csup\u003e(\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/sup\u003e. Training providers in compassionate care and ensuring gender-sensitive service delivery are essential components of successful screening programs. Another consistent theme across global and SSA literature is the role of peer and community influence. This study found that women were more likely to seek screening after hearing positive testimonies from friends or community members. Community-based mobilization, therefore, holds strong potential. Studies in Zambia and Nigeria have demonstrated that engaging community health workers and local champions can significantly increase awareness and service uptake\u003csup\u003e(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/sup\u003e. Uganda\u0026rsquo;s use of Village Health Teams (VHTs) offers a promising platform for scaling up such efforts.\u003c/p\u003e\u003cp\u003eGender dynamics also emerged as a powerful force shaping decision-making. In patriarchal settings, women often require permission from their husbands to access health services. Some participants in this study reported spousal resistance, with screening perceived as unnecessary or suspicious. This is a barrier echoed across SSA, where male involvement in reproductive health is often minimal. Programs in Kenya and Tanzania have begun involving men through couple-based health education, with promising outcomes in improving uptake and reducing gender-related stigma\u003csup\u003e(\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eSystemic barriers including supply shortages, understaffing, and informal charges further limit access. Although cervical cancer screening is officially free in Uganda\u0026rsquo;s public health system, hidden costs such as buying gloves or transport fees disproportionately affect low-income women. Similar issues have been noted in Ethiopia and Ghana, where out-of-pocket expenses were major deterrents\u003csup\u003e(\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e)\u003c/sup\u003e. Policymakers must ensure that funding mechanisms are in place to sustain service delivery and remove financial barriers.\u003c/p\u003e\u003cp\u003eThis study also highlighted the potential of integrating cervical cancer screening into other reproductive and maternal health services. Participants suggested offering screening during antenatal care (ANC) visits or immunization campaigns. Evidence from Rwanda and Malawi supports this integration approach, which has been shown to increase coverage without overwhelming existing systems\u003csup\u003e(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e)\u003c/sup\u003e. In Uganda, where ANC attendance is relatively high, leveraging these touchpoints could significantly improve screening rates. From a policy perspective, the study supports the need for a multi-pronged, context-specific strategy. Educational campaigns must be localized, involve trusted community figures, and incorporate culturally relevant content. Health systems must prioritize respectful, confidential, and accessible service environments. Community engagement, particularly through testimonies from survivors and outreach by VHTs, is critical to reducing stigma and building trust.\u003c/p\u003e\u003cp\u003eImportantly, this research provides evidence for rethinking national cervical cancer prevention strategies. Uganda\u0026rsquo;s National Strategic Plan (2020\u0026ndash;2024) outlines goals for HPV vaccination, screening, and treatment. However, achieving these goals will require overcoming entrenched social and systemic obstacles, as documented in this study. Greater investment in community education, healthcare provider training, and mobile outreach services is essential.\u003c/p\u003e\u003cp\u003eThe study\u0026rsquo;s qualitative design enabled a rich, in-depth understanding of the factors influencing screening behavior. However, it also has limitations. The findings are context-specific and may not fully reflect the diversity of experiences across Uganda. Moreover, the perspectives of men and healthcare policymakers were not thoroughly explored. Future research could build on these findings through larger mixed-methods studies or intervention trials to test community-driven strategies.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eCervical cancer screening remains critically underused in Uganda and across SSA due to misinformation, fear, gender dynamics, and systemic issues. This study adds to growing evidence advocating for tailored, targeted, culturally sensistive, community-based, and system-strengthening interventions. Achieving the global goal of eliminating cervical cancer by 2030, as outlined by WHO, will require local actions based on the lived experiences of women like those in Wakiso District.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAPHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAMBSO Population Health Surveillance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSSA\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSub-Saharan Africa\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eANC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntenatal Care\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eVHT\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eVillage Health Teams\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIUD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIntrauterine Device\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAMBSO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAfrica Medical and Behavioral Sciences Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eGBV\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eGender- Based Violence\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained from Clark International University- Research Ethics Committee (CIU-REC), and the study was registered by the Uganda National Council for Science and Technology (UNCST). Participation in the study was voluntary, and participants provided written informed consent after they were explained to the details of the study, including the benefits and risks of participation, and the study adhered to the Declaration of Helsinki guidelines.\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\u003eData are available upon request from the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSincere appreciation goes to Wakiso District Local Government, the National Institute of Health and Care Research (NIHR) and the Royal School of Tropical Medicine and Hygiene (RSTMH) Early Careers Research Program for supporting the conduct of this research study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eRMB and GN conceived the study, contributed to its design, data collection and analysis and drafted the manuscript. RN, RN,JN, APM, WB, JBN, \u0026nbsp;contributed in designing the study tools, data analysis and critical review of the manuscript. EK, SM, GK, FN, GKN, VN AD, AME, RN, EM, and SW, contributed to the review of the tools, research project administration and review of the manuscript.\u003c/p\u003e\n\u003cp\u003eAll authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to thank the study participants for their time. We would also like to thank AMBSO\u0026rsquo;s research team for their tireless efforts during the field activities.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eBruni L, Serrano B, Roura E, Alemany L, Cowan M, Herrero R et al. Cervical cancer screening programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis. 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Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://dx.doi.org/10.1186/s12879-016-1539-6\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7603002/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7603002/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCervical cancer is a leading cause of cancer-related morbidity and mortality among women in low-resource settings. Despite the availability of screening services in Uganda, uptake remains unacceptably low.\u003c/p\u003e\u003ch2\u003eObjectives\u003c/h2\u003e\u003cp\u003eTo explore perceptions, attitudes, knowledge, and barriers to cervical cancer screening among women aged 25 to 65 years in the urban and rural areas of Wakiso District, Uganda.\u003c/p\u003e\u003ch2\u003eDesign and setting:\u003c/h2\u003e\u003cp\u003eWe conducted focus group discussions (FGDs) and key informant interviews (KIIs) in the urban and rural communities within Wakiso District, Central Uganda.\u003c/p\u003e\u003ch2\u003eParticipants:\u003c/h2\u003e\u003cp\u003eSix focus group discussions (three in rural and three in urban) with sixty women aged between 25\u0026ndash;65 years and four key informant interviews with healthcare workers and administrators.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eKnowledge levels varied regarding cervical cancer risk factors, causes, signs, symptoms, and prevention. FGD participants linked cervical cancer to risky sexual behaviors, particularly involving multiple sexual partners or sexual intercourse with uncircumcised men, while some key informants said that some women believed that the disease was due to witchcraft. Concerns were also raised about family planning methods such as IUDs and pills, which some participants believed to cause cervical cancer. Poor hygiene practices, including the use of unclean public toilets and poor menstrual hygiene, were also seen as risk factors. Myths and misconceptions about cervical cancer screening, such as fears of removal of the cervix during screening, were prevalent. Although some women had positive experiences with screening, concerns about pain, discomfort, and limited privacy during screening were commonly reported.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eWhile knowledge of cervical cancer exists among women in Wakiso District, significant misconceptions, fears, and systemic barriers impede screening uptake. Culturally sensitive health education and accessible, respectful screening services are critical to improving participation.\u003c/p\u003e","manuscriptTitle":"“Even with one Man, but with many women, you can get Cervical Cancer”: Qualitative exploration of Women’s Perceptions and Experienced barriers to cervical cancer screening in Uganda","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-14 17:25:34","doi":"10.21203/rs.3.rs-7603002/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0a257e62-72ef-4f1b-8f11-6434db429ac4","owner":[],"postedDate":"October 14th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-02T11:08:18+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-14 17:25:34","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7603002","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7603002","identity":"rs-7603002","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}