Barriers to cervical cancer screening practices among women in Gishu County, Kenya

Research Paper (postgraduate), 2018

131 Pages



This research project is my original work and has not been published or presented for an examination in any institution.

Hillary Mirera Mabeya

Ghent University, Belgium


This is dedicated to cervical cancer patients and their families


I take this opportunity to acknowledge the invaluable input of the various stakeholders in this project; the staff of the Gynocare Fistula Centre Eldoret, for the help accorded me throughout the study. To the patients and their care givers in Gynocare Fistula hospital Eldoret who collaborated with me as my key respondents. Your role in this study was fundamental. Thank you for making time to interact with me and sharing your life experiences with cervical cancer. Your input is highly regarded. Thank you and God bless you always.

This study would not have been possible without the material and emotional support you accorded me by my wife Caroline Mabeya for your patience, love, understanding, sacrifice and support and my daughters Melanie, Antoinette and Hope. They kept me awake for long night throughout the entire process. Exceptional gratitude goes to the respondents who willingly and passionately shared their stories without fear .

My family, I thank God for all of you. Dad and Mum, your input and encouragement gave me a reason to keep on going on. I have come this far because you walked with me. To God for life and chance, that I could do this. Thank you for my colleagues in Moi University, School of Medicine, Department of Reproductive Health, study participants, family and friends that were part of my research and entire study. I thank you God for everything.





Table of Contents

List of Tables


1.1 Background of the Study
1.2 Problem Statement
1.3 General Objective
1.3.1 Specific Objectives
1.4 Research Questions
1.5 Justification of the study
1.6 Significance of the study
1.7 Scope and Limitation of the study
1.7.1 Scope of the study
1.7.2 Limitation of the study
1.8 Operational Definitions of Terms
1.9 Organization of the rest of the study
1.10 Organization of the rest of the study

2.0 Introduction
2.1 Knowledge Level about Cervical Cancer and Screening Practices
2.2 Perceptions and Attitudes towards Cervical Cancer and Screening Practices
2.3 Level of Cervical Screening Utilization&Variations between Rural&Urban Women
2.4 Factors act as Barriers to the Utilization of Cervical Cancer Screening Practices
2.5 Summary of Literature Review
2.6 Theoretical framework

3.0 Introduction
3.1 Study Sites
3.1.1 Study Population
3.2 Study Design
3. 3. Data collection instruments/Methods
3.3.1 Sources of Data
3.3.2 Qualitative Data
3.3.3 Quantitative Data
3.4 Sample procedure
3.5 Sample Size
3.5.1 Inclusion and exclusion criteria
3.6 Data collection Procedure
3.7 Data Management and Analysis
3.8 Ethical Consideration Issues

4.0 Introduction
4.1 Descriptive Analysis of the Sample Statistics
4.1.1 Demographic Characteristics of Respondent’s Women
4.2 Knowledge level about cervical cancer and screening practices
4.3 Perceptions and attitudes towards cervical cancer and screening practices
4.3.1 Perceived Severity and vulnerability to Cervical Cancer
4.3.2 Perceived present Broad Health Status of urban and rural women
4.3.3 Attitudes towards Cervical Screening Practices
4.4 Comparison of the level of CC screening & utilization of urban and rural women
4.4.1 Utilization of Cervical screening services
4.4.2 Time since Last Screened Cervical Cancer
4.4.3 Reasons for Cervical Cancer Screening
4.5 Barriers to the utilization of CC screening practices in Uasin Gishu County
4.6 Summary

5.0 Introduction
5.1 Discussion of the findings
5.1.1 Socio-Demographic Findings of Respondent’s Women
5.1.2 Knowledge level about cervical cancer and screening practices
5.1.3 Perceptions and attitudes towards cervical cancer and screening practices
5.1.4 Level of cervical screening utilization among rural and urban women
5.1.5 Factors that functions as barriers to the utilization of CC screening practices
5.2 Conclusion
5.3 Recommendations
5.4 Recommendations areas for further research



Appendices I

Appendices II Questionnaire

Appendices III Semi-Structured Interview


Table 4.1 Demographic characteristics of women participants

Table 4.2 Knowledge and understanding about Cervical Cancer

Table 4.3 Perceived Severity and vulnerability to Cervical Cancer

Table 4.4 Perceived present broad Status by Residence Category

Table 4.5 Attitudes toward Cervical Screening (Pap smear) by Residence Category

Table 4.6 Utilization of CS services (Pap smear) by Residence Category

Table 4.7 Time since Last Screened for Cervical Cancer

Table 4.8 Reasons for Cervical Cancer Screening

Table 4.9 Barriers to the cervical cancer screening


The study focused on factors that act as barriers to the utilization of cervical cancer screening practices among women living in Uasin Gishu County, Kenya. The objectives of study were to describe the knowledge level about cervical cancer and screening practices (causes, risk factors and early detection) among women living in Uasin Gishu County, to describe women’ perceptions and attitudes towards cervical cancer and screening practices, to determine the level of cervical screening utilization and whether cervical screening practices vary between rural and urban women living in Uasin Gushy County and to identify factors that functions as barriers to the utilization of cervical cancer screening practices among women living in Uasin Gishu County. The study adopted a cross sectional research design that applied both quantitative and qualitative methods of data collection including combination of interviews and questionnaires. Since cervical cancer affects only women, the study took as its target population women. Therefore, the study population comprised of women aged between 18 and 55 years with different social, economic and ethnic backgrounds and resided in both urban and rural areas Uasin Gishu County, Kenya. The finding of the study confirmed that many women living in Uasin Gishu County, Kenya had heard about cervical cancer yet the majority of the women had a poor knowledge in many characteristics of cervical cancer. Disparity was also observed in the knowledge of cervical cancer by the women. In view of the knowledge discrepancy about cervical cancer in the women, there is need for the Ministry of Health in Kenya to strengthen training programs and in-service education so that nurses and other health workers update their knowledge of cervical cancer and screening so that they circulate the same type of information. There is need for massive awareness on cervical cancer prevention by all community and government structures with Civil Society Organizations and local governments in the affected areas taking lead is needed at all levels; this has to include highlighting issues and effects of early marriages and early pregnancies as these predispose young girls to cervical cancer. Health workers need to use every health service / visit opportunity to provide information to women about cervical cancer. The creation of a Health Awareness Day could also go far in spreading information and empowering women in health related matters. Develop clear and simple educational messages about cervical cancer and the screening test that can easily be understood by both urban and rural women of Kenya and appropriately communicated to them.

Keywords: Cervical Cancer, Cervical Screening Utilization, Access, Barriers, Rural and Urban Women, perceptions and attitudes, Uasin Gishu County of Kenya,


Dr. Hillary Mirera Mabeya, born in 1967 in Kisii, Kenya. He got his first and Master Degrees from University of Nairobi. Currently, undergoing PhD in cervical cancer at Ghent University, Belgium. Presently, Dr. Mabeya is a lecturer in Moi University school of Medicine and director of Gynocare Fistula Centre Uasin Gishu County, Kenya



1.1 Background of the Study

In Kenya, cervical cancer is responsible for approximately 2000 fatalities per annum; making it the second most prevalent cancer after breast cancer (WHO/ICO, 2013). Annually, cervical cancer occurs in Kenya in 16.5 out of every 100,000 women, at an average age of 28.7 (WHO, 2013). These figures show an increase from the 2010 statistics, in which 1,676 women in Kenya died from cervical cancer (WHO/ICO 2010). It is crucial that Kenya should implement preventive and intervention measures so as to deal with the impact of cervical cancer. As is the case in other developing nations, Kenya faces resource constraints in addition to management challenges in dealing with cervical cancer.

The importance of screening increases in direct proportion to the rising number of diagnosed cases of cervical cancer. As the prevalence increases, awareness of the disease increases also. Thus awareness levels of cervical cancer in Kenya among women between 15 and 44 have risen to the extent that it is almost as well understood as breast cancer. This is important because approximately 38.8% of Kenyan women are estimated to be infected with the Human Papilloma Virus (HPV) the cause of cervical cancer at any given time (WHO / ICO 2010).

Global figures demonstrate the magnitude of cervical cancer. According to the IARC (2014) cervical cancer caused 265,653 deaths in 2012, from a reported 527,624 diagnoses, and therefore it is a significant global public health problem. This state of affairs is unfortunate, as cervical cancer is preventable. Indeed, in countries with advanced healthcare, the morbidity and mortality of cervical cancer have been in decline over fifty years due to intensive, routine screening programs and treatment of lesions before they become cancerous (Khan et al., 2014). However, in developing countries, prevalence and mortality due to cervical cancer has remained almost constant over the same five decade period, to the extent that 80% of all cervical cancer deaths occur in developing countries (Urasa and Darj, 2011; Frazer, 2006). However this is unlikely to change as screening, particularly using the Pap smear method, is either too expensive or too embarrassing for women in developing countries (Kawonga and Fonn, 2008).

According to recent estimates (WHO, 2014), the prevalence rate for all cancers will increase from 11.3 million cases in 2007 to 15.5 million cases in 2030, and that in 2050 almost two thirds of cancer cases will occur in developing countries (Cavalli, 2006). One method that has been proposed and implemented in combating cervical cancer is preventing HPV infection. HPV has been identified as the primary cause of cervical cancer. It is sexually transmitted and more than 100 types of the virus affect skin cells, and they are responsible for skin warts. About 40 types of HPV affect the mucosal epithelium, and some of these cause cervical cancer (Schnatz et al., 2008).

Cervical cancer begins when there is abnormal cell growth in the cervix (Bomela and Stevens, 2009). A woman's risk of developing cervical cancer is determined by the extent of her exposure to HPV. About 90% of HPV infections are resolved spontaneously within two years without symptoms, when the body's immune system combats the virus, while the remaining 10% may develop into cervical cancer (Shastri et al., 2014).

After the initial HPV infection, cervical cancer takes a long time to develop (ACCP 2004). Women typically contract HPV in their teens and twenties, but their immune systems prevent the virus from damaging their cervix. However, in a minority of infected women, HPV may live on the cervical surface for years before it makes some of the cervical cells turn cancerous (IARC 2007). Once this mutation happens, the cancerous cells grow and multiply into tumours which may be either benign or malignant. Malignant cervical cancer may metastasize in other parts of the body during the advanced stage of the disease (Ferlay et al., 2001).

Cervical cancer develops in four stages. In the first stage, the cancer is located in the cervix and can only be detected by a microscope (stage 1A). Stage 1B occurs when the cancer csn be detected visually or by physical examination. Stage 2 occurs when the cancer spreads beyond the cervix to involve neighbouring tissues, including the upper section of the vagina. Stage 3 occurs when the cancer spreads to the lower vagina or to the sides of the pelvis, or causes urethral obstruction (hydronephrosis). Metastasis occurs in stage 4, in which the cancer spreads to the bladder or rectum, or metastasizes to the liver or lungs. In stage 4, symptoms appear, such as fistula, fatigue, pain in the pelvis, back or legs, vaginal bleeding, and bone fractures (Ferlay et al., 2001).

Early age of sexual debut is a predisposing factor for HPV infection and cervical cancer. This factor is particularly significant in Kenya, where at least 33% of girls in secondary school have had sex, some of which is unprotected, exposing them to HPV (CAS 2009). Consequently, in the absence of interventions, approximately 10.32 million women aged over 15 years are at risk of developing cervical cancer (WHO/ICO, 2010).

Possible interventions include the Papanicolau (Pap) screening test which, as previously mentioned, has gradually (over 50 years) reduced cervical cancer mortality of disease by 50–60% in wealthy countries. Early detection means that women in developed countries can treat cervical cancer before becomes chronic and untreatable, and this has reduced mortality. Although there is greater awareness of screening in developing countries, demographic and economic obstacles hinder early detection and cervical cancer is frequently diagnosed in the advanced stage. This stage is too late for prevention, and so treatment focuses on the extremely costly options of pelvic surgery, radiotherapy, and chemotherapy. As a result, many women cannot afford these curative treatments and thus they face a chronic and persistent disease (Sellors et al., 2004).

Furthermore, in the developing world, due to personnel shortages and deficiencies in health system training and facilities, cervical cancer prevention remains almost random, as detection relies on low-resource visual inspection methods using acetic acid (VIA), or Lugol’s iodine (VILI) with a same-day-service, ‘see-and-treat’ method (WHO, 2013). However, the reported implementation of the aforementioned screening services is still low, which suggests that numerous social, cultural and economic obstacles prevent women from being screened (Gakidou et al., 2008).

1.2 Problem Statement

Although the causes and the means of preventing cervical cancer are well known, they have not been effectively implemented in Kenya (Sudenga et al., 2013). It is well established that screening for cervical cancer, and prompt treatment at the pre-cancerous stage, is an effective method of managing the disease (Chirenje, et al., 2001) alongside vaccination. However, due to the high cost and limited availability of vaccines in the developing world (DiAngi et al., 2011) screening and early treatment are considered more cost-effective methods of managing cervical cancer in developing countries.

Despite the acknowledgement of screening as the best way to approach cervical cancer treatment, it is apparent that the level of screening, particularly in Kenya, remains low (Adesina et al., 2013; Were et al., 2011). Thus there is need to examine the factors which contribute towards preventing women from getting screened for cervical cancer in Kenya. To address this problem, this study focused on Uasin Gishu County in western Kenya, and examined the problem from various aspects, namely women's knowledge level about cervical cancer and screening practices; women’s perceptions and attitudes towards cervical cancer and screening practices; the level of cervical screening utilization and whether cervical screening practices vary between rural and urban women; and the factors that function as barriers to the utilization of cervical cancer screening practices.

The foregoing aspects of the problem comprehensively cover the issue of barriers to cancer screening, and help to add to the knowledge about cervical cancer screening and barriers preventing it. Although these issues have been extensively studied in the developing world context, they have not been conclusively addressed within the study area, which is why the current study is necessary.

1.3 General Objective

The objective of this study was to explore factors that act as barriers to the utilization of cervical cancer screening practices among women living in Uasin Gishu County.

1.3.1 Specific Objectives

1. To describe the knowledge level about cervical cancer and screening practices (causes, risk factors and early detection) among women living in Uasin Gishu County.

2. To describe women’ perceptions and attitudes towards cervical cancer and screening practices.

3. To determine the level of cervical screening utilization and whether cervical screening practices vary between rural and urban women living in Uasin Gishu County

4. To identify factors that functions as barriers to the utilization of cervical cancer screening practices in Uasin Gishu County.

1.4 Research Questions

The study was guided by the following research questions:

1. What is the level of knowledge about cervical cancer and screening practices among women living in Uasin Gishu County?

2. What are the perceptions and attitudes towards cervical cancer and screening practices among women living in Uasin Gishu County Kenya?

3. What is the level of cervical screening utilization, and the differences in screening practices between rural and urban women living in Uasin Gishu County?

4. What are the factors that functions as barriers to the utilization of cervical cancer screening practices in Uasin Gishu County?

1.5 Justification of the study

A study by WHO projects that by the year 2025, the number of cervical cancer patients in Kenya will have reached 2,955 per year (WHO/ICO 2010). As with other cancers in developing countries, cervical cancer is diagnosed in the advanced stage. Therefore there is a need for studies like this to answer questions on current cervical cancer screening uptake, results of the screening and why targets have not been reached. Information about the barriers women face in seeking cervical cancer prevention services can be used to guide implementation of new services and improvements in currently available services. This study aimed to identify the factors that act as barriers to the utilization of cervical cancer screening practices among women living in Uasin Gishu County, Kenya. The generated information can be applied in policy making and strengthen outreach programs. This will then assist programs in tailoring their services to reach women and increase coverage rates. There is a need to explore to identify the factors that act as barriers to the utilization of cervical cancer screening practices among women. Besides adding to existing medical literature on chronic illnesses, the study findings will inform policies aimed at better management and care of cervical cancer patients, and other chronic illnesses.

1.6 Significance of the Study

This study sought to determine identify factors that functions as barriers to the utilization of cervical cancer screening practices. Studies have shown that cervical cancer if detected early can be treated, yet this cancer is still one of the most common affecting Kenyan women today. It has been documented that most of the women report to diagnostic facilities late when treatment is not viable. It is of great importance to know what causes these delays and provide recommendations towards ensuring that the diseases can be controlled or prevented. The consequences of delayed diagnosis include advancement of disease to other organs resulting in more morbidity, reduced survival rate and mortality. It also has cost implications of maintaining long term patients on palliative care. A desired goal for cervical cancer is early diagnosis which leads to early treatment and cure. The most common age affected by cervical cancer is between 35 to 50 years. These are women who are still highly productive in society. These women have a high chance of survival when the disease is discovered early. Knowledge on the barriers to the utilization of cervical cancer screening practices will complement efforts to prevent the disease.

Women especially in the rural areas of Uasin Gishu County have less access to cervical cancer awareness programmes hence they have limited information on cervical cancer, prevention strategies and importance of screening practices. Some traditional beliefs and practices such as use of traditional medicine compound to this lack of knowledge. Dissemination of information on cervical cancer at the community level is therefore important as it will encourage women to drop such practices and seek medical advice early. Sensitive advocacy in these areas is essential in order to achieve the vision 2030 goal on elimination of preventable diseases in Kenya. The results of this study will be utilized by the Ministry of Health to plan and prioritize activities geared at reducing cervical cancer in Kenya. The Kenya Cancer Association (KENCASA) is a Non Governmental Organization involved in advocacy, awareness creation and screening of cancer. The findings of this study will be presented to KENCASA to utilize in precedence their activities.

The findings of this study may serve as evidence that more awareness campaigns on cervical cancer especially in the rural areas is required. The research findings could also be used as a reference for other studies that could be conducted in the future. It is hoped that the findings of the study will contribute towards recommendations to improving the use of cervical cancer screening programs by women in Kenya. The study will probably identify barriers to programs and these will be communicated to the appropriate authorities so that women's health issues are addressed. The results will address the knowledge gap in understanding the women's health issues in Uasin Gishu County, Kenya, and how cervical cancer impacts on life of women. In addition findings from the study will be published in a peer reviewed journal and may be used to facilitate commencement, evaluation or enhancement of cervical cancer screening programs.

1.7 Scope and Limitation of the study

1.7.1 Scope of the study

This research aims to identify and understand the barriers to cervical cancer screening practices among women in Gishu County, Kenya. This research was restricted to rural and urban women living in Uasin Gishu County. The study was also focused on capturing women’s that access hospital and health center for cervical cancer screening .

1.7.2 Limitation of the study

The study also has a number of limitations, which should be considered when interpreting the results. First, participants were randomly sampled and the study was limited only to Uasin Gishu. Therefore the findings cannot be generalized to the overall population of women in Kenya. Second, some sub-populations were excluded, such as those women living in Uasin Gishu County who could not read or speak English. This is an important limitation as these women are more likely to face language and communication barriers when accessing health care and therefore may be less likely to engage in health education programs and cervical screening utilization. Other groups of women were also under-represented, such as those with lower levels of education. Low levels of literacy, even in their home language, can be a significant barrier to health promotion interventions. The study acknowledges the over-representation of educated women in the sample and that the results may not be a true reflection of the experiences of other women living in Uasin Gishu County. However, the low level of knowledge about cervical cancer and screening observed among this well-educated group of women is of concern. This suggests the need for continuous health interventions to increase health literacy and awareness of cervical cancer and screening in the participants’ communities. Third, semi-structured interviews could not be conducted with Muslim women. Despite several attempts on the part of the researcher to schedule interview sessions with a number of the Muslim women who participated in the survey, these women declined to participate in the semi-structured interview. This may have some implications on the study findings. For instance the study may have missed out on information regarding the particular views and experiences of Muslim women, the appropriateness of health promotion activities for these women in mosques or the involvement of Muslim religious leaders in health promotion activities.

Fourthly, the study also acknowledges that data in this study were self-reported, which may have introduced some recall bias or produced socially desirable responses leading to participants under-reporting or over-reporting information. Given the qualitative nature of the study as well as the sensitivity of the research topic, only a small number of participants were involved and this limits the generalization of the study results. Therefore, the small participant pool and the specific geographical focus of this study limit the generalizability of these results. However, this study has identified themes that are highly relevant for the target County and population, with a good chance that recommendations may hold for other Counties in Kenya with similar demographic characteristics.

1.8 Operational Definitionsof Terms

For the purpose of this study, the following definitions will be applied and used within the context in which they are explained:

Barriers mean anything that acts as a hindrance to cervical cancer screening uptake by urban and rural women in Uasin Gishu County.

Cervical cancer- means a disease in which cancer cells grow in the cervix.

Cervical cancer screening - means any procedure used to detect abnormal cells of the cervix. In this study, screening procedures refer to VIA or a Pap smear.

Health-seeking behaviour – any conscious action by a person in response to an illness and for the purpose of finding remedy

Opportunistic screening – when an individual visit a health facility and makes contact with a health professional for a particular reason other than for screening purposes and the screening test is offered (Espinas et al., 2011).

Organized screening – when individuals in a pre-defined age group are invited for screening at pre-defined intervals

Pap smear test – a test study of exfoliated cells from the cervix. Pap smear and Pap test are used interchangeably.

Reproductive health clinics- means Family Planning and Sexually Transmitted Infection clinics

Rural women - means those women staying in any area outside Eldoret the capital of Uasin Gishu County.

Screening - is the systematic application of a test or inquiry, to identify individuals at sufficient risk of a specific disorder to benefit from further investigation or direct preventive action, among persons who have sought medical attention on account of symptoms of that disorder (Wald, 2008, p. 50).

Under-screened woman - women who are screened below the national recommended screening requirement.

Unscreened women – women who have never had a Pap smear

Urban women - means those women staying in any area within Eldoret the capital of Uasin Gishu County.

1.9 Organization of the rest of the study

This study was organized in five chapters. Chapter one includes an outline of the chapters that follow in the study. It gives the background to the study, statement of the problem, research questions, and objectives of the study, significance and justification of the study, the scope and limitations of the study, definition of terms, conceptual framework, organization of the rest of the study and chapter summary. Chapter two presents review of related literature. The literature focuses on factors that act as barriers to the utilization of cervical cancer screening practices among women living in Uasin Gishu County. Chapter three outlines the research design and methodology. The chapter explains the research setting, the study design, the sample size, the research instruments, the procedure followed in obtaining the information, the analysis used to interpret the information and the ethical issues. Chapter four, presents the research findings, it focuses on the analysis, interpretation and discussion of the study findings. Chapter five, discusses the results, presents a summary of the whole study and discussion of the findings of the study with a view to crystallize the specific findings in relation to the research objectives and in light of the hypothetical and empirical literatures.

1.10 Chapter Summary

This chapter has outlined the background, statement of the problem, objectives of the Study, research questions, justification, significance of the study, scope and limitation of the study the study, definition of terms organizations of the rest of the study and chapter summary. The review of the related literature was presented in the subsequent chapter two that follow chapter one.



2.0 Introduction

This chapter critically reviews the empirical literature on cervical cancer, cervical screening and the health promotion interventions that can potentially influence cervical screening uptake among women. In this chapter, discussion were focus on a general overview of cervical cancer, knowledge level about cervical cancer and screening practices (causes, risk factors and early detection), women’ perceptions and attitudes towards cervical cancer and screening practices, women’ perception of their vulnerability to cervical cancer, the level of cervical screening utilization, factors that function as barriers to the utilization of cervical cancer screening practices and associations between demographics, knowledge, barriers, and screening behaviour of women. In addition a theoretical framework was utilized to guide the study. Thereafter a summary was done to show how unique the study is. This chapter has been subdivided into sub-sections under the following headings:

2.1 Knowledge Level about Cervical Cancer and Screening Practices

Healthcare professionals in Kenya have reported interviewing and treating a large number of patients who have little or no knowledge of cervical cancer. This acute lack of awareness of the signs and symptoms of cervical cancer as well as the prevention and treatment methods available were mentioned as significant problem by healthcare professionals (Kivuti-Bitok et al., 2013). They also stated that educating the public about all aspects of cervical cancer should not be the sole responsibility of the government, and that healthcare providers and the private sector should also play a role. Healthcare professionals interviewed by the author were convinced that cell phones could be used to disseminate information about cervical cancer and other conditions, and that this could be even more effective with the engagement and participation of healthcare workers (Kivuti-Bitok et al., 2013). Nevertheless, healthcare professionals are conscious that disseminating information alone cannot solve the problem of low levels of screening. On the contrary, they acknowledge that too much information, without feedback, may be counter-productive, as they reported that women are reluctant to undergo pap smears, especially if they are aware that scraping of the cervix for cell samples may create a wound which makes them susceptible to HIV infection, thereby resulting in even lower levels of screening (Kivuti-Bitok et al., 2013).

In addition to low levels of knowledge about cervical cancer, there are numerous other challenges which prevent Kenyan healthcare professionals from effectively screening for cervical cancer. These challenges affect healthcare professionals individually; they may be related to healthcare facilities and technology, or to the patients themselves. In terms of the personnel/facility challenges, it has been found that there are not enough healthcare workers to either screen or educate patients about cervical cancer, thus very few patients get screened (Denny et al., 2006; Bingham et al., 2003).

In terms of technology, health facilities and professionals in Africa are adversely affected by the digital divide, so access to Information Communication Technologies is a problem, as well as computer skills. Although the growing use of smartphones may help solve this problem, there is still the issue of how to access reliable data on cervical cancer. Lack of ICT skills may lead to healthcare professionals lacking current knowledge of evidence based practice. This is compounded by the lack of computers and ICT competent staff in Kenyan public hospitals (Kivuti-Bitok et al., 2013).

It isn't only African countries that struggle with cervical cancer screening. From Qatar and Turkey respectively, Al-Meer et al., (2011) and Reis et al., (2012) report that poor public knowledge of cervical cancer screening techniques leads to low levels of screening. In Turkey, Yilmazel and Duman (2014) report that the other prevention alternative, vaccination, is expensive and may not be available to the majority of women. In Iran, the pap smear is the main screening method for cervical cancer, but Karimi et al., (2012) found that women were uncomfortable with this method. Iran has a rigorous screening system for cervical cancer, which is exclusive for married women and begins with a pap smear at 18 years, followed by a pap smear test every three years. However, cancer mortality rates in Iran have actually increased, from 350 in 2005, 600 in 2006 and 663 in 2007 (Vaisy et al., 2012).

Low levels of awareness and misconceptions about cervical cancer screening, and lack of knowledge about symptoms and causes of the disease, would lead to women avoiding screening. This concurs with the finding that individuals’ knowledge and attitude correlate with their healthcare-seeking behaviours (Birhanu et al., 2012; Saberi et al., 2012) and thus women who are better informed about cervical cancer and its prevention are more likely to be screened than women who know nothing about the disease.

Mutyaba et al., (2006) conducted a study In Uganda and found that below 40% of the respondents knew about cervical cancer and its risk factors. Concurrently, about 81% of the respondents had never been screened for cervical cancer. In another study, Mutyaba et al., (2007) found that ignorance about cervical cancer and its risk factors was an obstacle to screening. The situation is even more serious in Zimbabwe where it was found that 95.78% of respondent women had never been screened for cervical cancer and they knew next to nothing about the causes treatment and prevention of the disease. Therefore, the researchers recommended intensive public education of women about cervical cancer (Mangoma et al., 2006). In Moshi, Tanzania, Lyimo and Beran (2012) found that 59.6% of respondents, who were women aged from 18 to 69, knew very little about cervical cancer and its prevention. The researchers also found that only 12.6% of women, who had prior experience of screening, knew more about cervical cancer and its prevention.

A study in rural Nepal aimed at assessing women's knowledge of cervical cancer studied the effect of a community-based awareness program, which taught women's groups in rural Nepal about cervical cancer and its prevention. The study tested women's basic knowledge of risk factors, symptoms and perceived risks of cervical cancer. At the start of the awareness program, only 6 % of respondents had heard about cervical cancer, and their basic knowledge of risk factors and symptoms was poor. However, the percentage of women willing to be screened for cervical cancer increased from 15.6% to 100 % after attending the community-based awareness program. In addition, the respondents recruited 222 more women from among their peers for screening (Shakya et al, 2015).

This confirms the findings of Nwankwo et al., (2011) in Nigeria, who cited lack of information and institutional neglect of women's healthcare as among the contributing factors towards the reluctance of women to attend cervical cancer screening services. Conversely, prior experience with reproductive health services is associated with greater awareness of cervical cancer screening in a population in India (Shastri et al., 2014).

When women know the risk factors for developing cervical cancer, it has been observed trhat there is better utilization of screening services. A woman's own accurate perception of her risk of developing cervical cancer is a significant indicator of action towards screening for cervical cancer. Concurrently, a woman's perception that she is not at risk is an indicator of low uptake of screening (Adesina et al, 2013). Furthermore, Nwankwo et al., (2011) found that high awareness about cervical cancer prevention is positively linked to a high level of formal education among women. The researchers proposed that education contributed to awareness of both the cervical cancer and the availability of screening services. Therefore, the researchers encouraged the emphasis on educating girls, and advocated for intensive, continuous use of print and electronic media to create awareness and to educate the general public.

2.2 Perceptions and Attitudes towards Cervical Cancer and Screening Practices

Vaccination has been mentioned as an alternative to screening. It is thought to be more culturally acceptable than screening. This is supported in studies done among women by Becker-Dreps et al., (2010) in Kenya and Diangi et al., (2011) in Botswana who found high level of acceptability of HPV vaccines but low level of knowledge on HPV Vaccine. The positive attitude towards vaccination may be related to its being less invasive to privacy and less embarrassing. The positive attitude towards HPV vaccine is a strength which the stakeholders would base HPV vaccine on in these countries (Kivuti-Bitok et al., 2013). However, the cost and difficulty in accessing the vaccine may make this option less practical than screening in the short term.

Worldwide, cultural beliefs, myths and stigmas about cancer are numerous. Cultural beliefs have reduced screening rates and have hindered health-seeking for cervical cancer (Daher, 2012). Consequently successful screening programs require culture-specific interventions to reduce or eliminate stigma. Government program managers and agencies in developing countries need to implement culturally sensitive approaches to debunk potentially harmful beliefs about cervical cancer. In addition, medical schools and other health training institutions need to initiate and enhance cultural sensitivity courses into their curricula in order for health-care professionals to provide culturally appropriate care to their patients (Fang and Baker, 2013).

The cultural sensitivity of cervical cancer screening is demonstrated by the issue of parity. High parity is a risk factor for cervical cancer, yet it is under-reported in studies in sub-Saharan Africa. In South Africa, only 44% of respondents were aware of high parity as a risk factor for cervical cancer (Maree et al., 2011) while in Kenya, high parity and early onset of sexual activity were completely unreported (Gatune and Nyamongo, 2005). The under-reporting of high parity may be due to the fact that most respondents have experienced high parity themselves and would probably feel uncomfortable to perceive themselves to be at risk of cervical cancer – a form of self-serving bias (Duval and Silvia, 2002). Alternatively, under-reporting high parity may be due to prevalent sociocultural beliefs favouring large families, based on the value of children as sources of wealth and security (Dyer, 2007).

Women’s ability to make and act on informed decisions is affected by prevailing social networks, institutions or the community, in addition to their own beliefs and behavioural patterns. Social networks include women’s partners, family, friends, neighbours, and members of women’s groups or religious groups with which she may be affiliated. Other barriers to informed consent include shyness, embarrassment, fear of pain or the test results (ACCP, 2004).

Indeed, “Cultural beliefs and custom barriers faced by women in most cases make [them] shy to discuss their problems and getting examined by the male health professionals may lead to decreased screening especially [among] Muslim women. An effective program for cancer of the cervix screening should target both gender[s] as male partners have a role to encourage their spouses to be screened and male leaders can promote women participation in cancer of the cervix screening processes irrespective of their marital status'” (Shastri et al., 2014: 107).

Similarly, “a significant cancer of the cervix screening barrier cited by women in both the developing and developed world is embarrassment. Embarrassment in gynaecological screening is a well-known but ill-defined phenomenon. From screening for sexually transmitted infections to cancer of the cervix, many women cite embarrassment as the reason for not participating in screening, yet little is known about the specific components of screening that are most embarrassing and the wider impact this has on screening uptake and adherence. Some of the issues contributing to embarrassment include lack of privacy, discomfort with sexuality, fear of judgement and religious rationale. Embarrassment is commonly viewed as a static psychosocial barrier with little discussion on how it can evolve and dissipate. With such strong psychosocial barriers to screening, it follows that compliance with future testing or initiating screening at all may be threatened” (Flora et al, 2014: 5).

“Beliefs and attitudes towards the concept of prevention may also affect utilization of services where understanding of prevention is sometimes limited. For example, women interviewed in Western Kenya reported that it is often problematic for a woman to go to a health clinic to be screened if she is “feeling healthy,” as she must convince her partner to get money for transport when she is not visibly ill. Furthermore, results from the PAHO analysis of qualitative studies in Latin America and the Caribbean suggest that women generally do not distinguish among types of cancer affecting women's reproductive organs and, therefore, do not readily understand that cancer of the cervix is a preventable disease. Many women and their male partners, especially in rural areas, have a limited understanding of female reproductive organs and associated diseases. In many project settings, women sometimes erroneously believe that cervical screening tests also are used to detect STIs or HIV, and thus, may decide not to get screened. In South Africa, for instance, women often believe that a positive screening test means that they have AIDS. This view also prevailed in western Kenya where cervical screening often is confused with the “AIDS test” or with STI testing because women have been told that cancer of the cervix is caused by human papillomavirus (HPV). Further, positive STI test results often are viewed as proof of marital infidelity. Because of these stigmas, some women are especially fearful about explaining the results of these examinations to their spouses, and therefore may decide not to be screened” (Friedman et al., 2014: 857).

Fears stemming from negative images of cancer and gynecological care may hinder cancer of the cervix screening services. Women interviewed in a variety of countries reported having powerful and quite frightening images of cancer. These fears may contribute to a woman's reluctance to get screened. Images are associated with words such as “devour or eating”, “putridity”, or “plague”. For example, in Mexico, terms used to describe cancer of the cervix included “rotting or devouring of the womb.” Women in Kenya describe the inevitability of cancer of the cervix and the belief that, at a minimum, the womb will be “cut out,” resulting in the loss of womanhood and sexuality. In Mexico, women reported a fear that any treatment would leave them sexually disabled, and in Bolivia, women stated that cancer is a “death sentence” that condemns them to die slowly and painfully. In South Africa, the pelvic examination is referred to as “hanging the legs” and women refer to the experience as “surrendering oneself.” In this setting, a cervical examination is especially problematic because, unlike a pregnancy-related exam (which is viewed favourably by the community), a positive cervical screening test implies that she is somehow “dirty” or promiscuous. It also challenges the male partner's “ownership” of and control over his wife” (Friedman et al., 2014: 859).

“Another key factor in a woman's decision to participate in cancer of the cervix prevention services is her husband's positive emotional and, if needed, financial support. For instance, in western Kenya, community health workers noted that many women do not seek cervical screening services or make follow-up visits because their husbands provide little support or are actively opposed” (PATH, 2004: 17).

“There are a number of other, harder to quantify factors that also shape the utilization of screening services in Kenya. For example, the impressions that individuals and communities have from past interactions with the health services sector may influence their decision to seek healthcare in the future. If the population has a favourable view of health services, it follows that the utilization of health services will improve as more people seek care. Dissatisfaction with the health system affects health seeking behaviour. If an individual makes what is likely to be an arduous trip to a health facility only to discover that they are out of medicine, medical supplies or no staff on duty, the likelihood that the same individual will make the trip again in the future is lessened. When this scenario becomes commonplace, an entire community might become less likely to seek health services, even when they are needed. Low education levels, particularly in rural areas, may influence the ability of individuals to judge when care should be sought, while knowledge of what care is available and its potential benefits may be incomplete or totally unknown” (Dustin, 2010:2).

2.3 Level of Cervical Screening Utilization and Variations between Rural and Urban Women

Systematic screening, treatment programmes and effective HPV vaccination provides the best interventions for preventing cervical cancer among HIV women (WHO, 2014). The American College of Obstetricians and Gynaecologists defines cervical cancer screening as an approach that is used to find changes in the cells of the cervix that could eventually lead to cervical cancer. The objective of cervical cancer screening programmes is to reduce the mortality from (and incidence of) the disease by identifying women with precancerous cervical lesions and early invasive cancers, and treating these women appropriately.

Currently, cervical screening is acknowledged as the most effective approach for cervical cancer control. The success of any screening programme pivots around the functioning of that programme in its comprehensiveness. The requirements to attain universal screening include; the ability of a programme to ensure high levels of coverage of the target population, offer high quality caring services, develop and monitor good referral systems that ensure good patient follow-up and ensure that the patients receive appropriate, acceptable and caring treatment in the context of informed consent (WHO, 2002). However, majority of the Sub-Saharan countries do not possess the facilities to meet these requirements which partly explain why economic burden of cervical cancer is still high within these countries.

Several studies indicate cervical cancer screening is the most effective and efficient mechanism of preventing cervical cancer. These studies note that, even if a woman were screened for cervical cancer only once in her lifetime between the ages of 30 and 40, her risk of cancer would be reduced by 25-36 % (Goldie et al., 2005). Cervical cancer can be prevented by identifying pre-cancerous lesions early using Pap smear, VIA and cytology screening and treat these lesions before they advance to cancer.

In low resource settings, the optimal age-group for cervical cancer screening that achieves the greatest public health impact is between 30-39 years of age. Screening programmes can lead to a significant reduction in the morbidity and mortality associated with this cancer. Several studies have indicated that if a woman aged 35 years old is screened only once in her life, a single-visit or two-visit approach with the VIA method; this could reduce the lifetime risk of cervical cancer by 25% and HPV DNA testing could reduce it by 36% (Sherris et al., 2009).

However, screening is only effective if there is a well-organized system for follow-up and treatment for women with abnormalities. This is done to prevent the development of cancer or to treat cancer at an early stage (WHO, 2002). Unfortunately, the fragmented nature of various healthcare systems in developing countries has retarded systematic cervical cancer screening since it does not provide follow-up after screening especially for those patients sent to referrals. Secondly, the treatment of cervical cancer is extremely expensive for many low-income households. Thus, an overall improvement healthcare system has a big impact towards ensuring better screening outcomes.

Cytology-based screening involves using either conventional cervical cytology (Pap smears) or liquid based cytology. These entail the collection of cell samples from the cervix followed by slide preparation, staining, reading and reporting. This procedure requires a doctor or a nurse to gather the samples; sufficient and consistently available supplies and equipment must be provided to collect and process the smears (Sherris et al., 2009). This implies that cytology based screening requires well-established health systems which are non-existent in many developing countries. Also cytological screening test is available only in urban health centres or private laboratories; and access to these sites is difficult for rural women. This finding concurs with other studies (Birhanu et al., 2012; Kivuti-Bitok, 2013).

Kamulegeya et al., (2014) conducted a study to determine the uptake of cervical cancer screening among women aged 25-49 years in Nakasongola District – Uganda. A cross-sectional community survey of 526 women was interviewed. Only 14.6% of the women reported to have screened for cervical cancer and 79.2% of these had done so within the district. Only 6.5% had screened two or more times and their willingness to adhere to the next screening appointment was almost universal. The above studies clearly indicate that the level of utilization of cervical cancer screening among women in Uganda is very low.

Comparable studies carried out in Kenya revealed that few women seek cervical cancer screening which partly explains why 4802 women are diagnosed with cervical cancer every year. Around 9.1% of women in the general population are approximated to harbour cervical HPV-16/18 infection at a given time and 61.4% of the invasive cervical cancer cases are attributed to HPV 16 or 18. The cross-sectional questionnaire survey conducted at Moi Teaching and Referral Hospital revealed that only 29.937 women out of 216 had ever received cervical cancer screening (Were et al., 2011). Another cross-sectional survey involving 388 women seeking reproductive health services in Kisumu found out that 6% had been screened despite that fact 29% had previously heard about cervical cancer. These mainly received this information from health workers (Sudenga et al., 2013).

In Tanzania, a cross sectional study sampled 512 primary school teachers; only 21% had been screened for cervical cancer and the utilization of cervical cancer services was about 28% among women aged 20-29 years (Kileo et al., 2015). These studies clearly indicate that very few women within the reproductive age seek cervical cancer screening among developing countries. This partly explains why many women within Sub-Saharan Africa present cervical cancer at a late stage whose prognosis is hard to treat.

In terms of the determinants of screening status, among the urban strata, older women were more likely to have ever been screened for cervical cancer, which may reflect more lifetime contact with health services and opportunities to be screened. Cervical cancer knowledge was a strong predictor of screening status, though only among urban women. While directionality of the association could not be assessed, knowledge of the disease and its prevention may motivate women to seek screening themselves and has been noted as an important determinant in most studies of cervical screening uptake (Abotchie and Shokar, 2009).

Lyimo and Beran (2012) noted that the distance to the nearest screening centre ranged from 2 km to 40 km and only half of the 419 respondents lived within 20km from nearest screening centre. This implied that the transport costs to access screening services were relatively high ranged from US$ 1.2 to US$ 40 with an average cost of US$ 17.2. The total costs incurred for services were reportedly prohibitive for service utilization among 89.7% of the respondents although this was not statistically significant.

In contrast, in rural areas, access barriers may prevent women from being screened even if they have previous knowledge of screening and/or health insurance. A previous study of screening uptake in the Moshi Rural district of Kilimanjaro noted that when all factors were examined simultaneously, only living close to a screening facility and knowledge of cervical cancer were significantly associated with screening status, and this knowledge may have been gained through the screening procedure itself (Lyimo and Beran, 2012).

Cervical cancer provides a unique public health and epidemiologic opportunity in contrast to most other cancers; it can be prevented at both primary and secondary levels. Primary prevention is based on vaccination for girls aged 11 and 12 years. Secondary prevention entails screening programs designed to identify and treat precancerous lesions referred to as high-grade squamous intraepithelial lesions (HSIL) (Kahesa, 2012).

2.4 Factors act as Barriers to the Utilization of Cervical Cancer Screening Practices

The poor access to, and poor quality of, cervical cancer-prevention and control services has hindered the standardised screening, treatment and efficiency of HPV vaccination. The uptake of cervical cancer screening services among women remains very low and this partly explains why the most women present cervical cancer at an invasive stage whose survival rate is very low. Furthermore, this reveals why there is a huge disparity in morbidity and mortality of cervical cancer between high and low-income countries (WHO/ICO, 2010).

Bingham et al., (2010) found that ineffective infrastructure as well as long distances between facilities and clients’ homes increase transportation costs and delay reporting results. Cervical cancer screening is associated with high costs which may not be affordable to most women (Weiderpass et al., 2007). At the Kenyatta National Referral Hospital, pap smear costs US$ 7. However, the client must pay for a file or identification card of US$ 6.50. The client then needs to wait for the pap results from the pathologist, which takes two weeks. At the leading private hospitals, Pap smear costs on average US$ 15 with a waiting time of 2 days for the pathology results. However at the public Hospitals, the Pap smear procedure is subsidized by the government and the client only pays US$ 0.25 for registration. The waiting period is however two weeks. Public Hospitals also make use of Visual Inspection with Acetic Acid (VIA) and Visual Inspection with Lugol’s Iodine (VILLI) as screening methods in low resource settings and results are available immediately. Of the few women who undergo screening, a large portion of them do not return for their test results (Denny et al., 2006).

Furthermore, cytology screening process is associated with the delays between screening, provision of test results and ultimate treatment, which make it less likely that test positive women will ever receive their results in low resource countries (Sherris et al, 2009). The challenges to implement sustainable and feasible cytology-based programs in low resource countries have inspired researchers to seek promising alternatives to Pap smear screening. The reasons for the high incidence and mortality from cervical cancer in sub-Saharan Africa include lack of awareness of cervical cancer among the population, health-care providers and policymakers; limited access to high-quality health-care services and cervical screening programmes; and lack of functional referral systems. All these lead to advanced stage at diagnoses. In developed countries, incidence and mortality from cervical cancer have been reduced through measures which include cytological screening and prompt treatment of early cervical lesions.

The low levels of cervical cancer screening have become a public health concern and a number of studies have been conducted to identify the barriers to effective utilization of cervical cancer screening in Sub-Saharan African countries. Thus, it is important to discuss these impediments because understanding these factors could guide future educational and policy interventions to increase cervical cancer screening within cost-effective frameworks (Kileo et al, 2015). These include; inadequate access to health services, inadequate information regarding cervical cancer among healthcare workers, and lack of awareness (Bingham et al, 2003).

The Pap smear, which has led to significant declines in cancer of the cervix incidence and mortality in the developed world, has limitations in low-resource settings. It requires a continuous supply of well-trained technicians and pathologists to review abnormal slides along with well-managed and effective service delivery systems. These elements often are not available in low-resource settings. In addition, follow-up of women is difficult (RTCOG/Jhpiego, 2003). Single visit approach using VIA/VILI and cryotherapy is a practical alternative because the screening approach is safe, relatively easy to perform, and the cost is low. The test can be done by various cadres of health care providers in almost any setting and results are available on time, which provides an opportunity to manage and reduces loss to follow-up (WHO, 2006).

For some women, especially those living in communities where there is minimal access to health care, the location of the service facility is an important determinant of participation in screening processes. Geographic inaccessibility remains a central barrier in most resource-poor settings, as a significant portion of the population at risk for cancer of the cervix may be located in areas where little or no coverage currently exists. In Peru, screening rates were much lower in districts where services were distant or difficult to access. Conversely, regional coverage rates were much higher where static services were more accessible to major population centres or where mobile campaigns brought services to women. In Mexico, and in Western Kenya, women reported that transportation costs and distance played a significant role in screening participation and loss to follow-up. In these rural areas, there is no public transport and women must pay for private transportation. Kenyan studies also show that many women must travel anywhere from two to eight hours, at an average cost of a day's agricultural wage. Community health workers in Kenya reported that some male partners do not permit their wives to seek screening because they do not want them travelling long distances, which often requires travel at night. Women come to clinics only when they are able to finance the trip, negotiate their home responsibilities, and obtain support from their husbands. When women do make the trip, they are not as likely to return if they are turned away or otherwise unable to be seen (Friedman et al., 2014).

The conditions under which counselling takes place, how effectively and respectfully the provider communicates information to the woman, the woman's ability to ask questions, the process of informed consent, and the respect for privacy and confidentiality all are important factors that influence a woman's experience with care. Screened women interviewed in Peru, Kenya, Mexico, and South Africa highlighted the importance of providers taking time to converse with them, answering questions, explaining procedures, and giving encouragement. Women appreciated being addressed by their names, and wanted providers to speak simply, softly, and gently, and avoid rude behaviour. Non-Spanish-speaking indigenous women who were interviewed in the Mexican study highlighted the importance of having an interpreter available at the clinic, as many do not seek services because of the language barrier (Friedman et al., 2014).

According to recent analysis on the health care utilization rate in Kenya by Wamai (2009), it revealed that approximately 77% of those who are sick seek medical attention, meaning that a large percentage of the population does not seek care despite being ill. In order to bring about broad improvements in health in Kenya, it is essential to understand who is currently using the facilities that are available, and what factors are preventing those who do not seek care from doing so (Dustin, 2010). The two most significant barriers to entry in the Kenyan health system are the cost of care, and the availability of suitable care within a reasonable distance (i.e., geographic barriers). According to NHSSP II, ―the physical [health] infrastructure in some regions of the country has coverage of one facility per 50-200 square kilometres, making the availability of health resources to those who are sick virtually non-existent in certain cases (MOPHS/MOMS, 2012).

Several factors hinder women from accessing screening services. Markovic et al (2005) investigated knowledge of and perceived barriers to screening for women in Serbia in order to understand their health needs. Nine focus group discussions with 62 women from diverse socio-economic backgrounds were conducted. Findings from the study revealed that the most important barriers to screening were inadequate public health education, lack of patient- friendly health services, socio-cultural health beliefs and gender roles.

Another study was conducted by Basu et al., (2006) on women's perceptions and social barriers as determinants of compliance to cervical cancer screening in India. This study was done in order to identify the immediate social and cultural barriers that prevent women from attending screening facilities. A sample size of 500 randomly selected non-compliant and compliant women to a community based cervical screening facility were interviewed. They found that, non compliant women had a significantly lower literacy rate compared to the compliant women. The study further found that though women were willing, they could not attend because of an inability to leave household chores, preoccupation with family problems and lack of approval from their husbands. Some had opted to stay away from the program because they had no symptoms of disease (Basu et al., 2006).

2.5 Summary of Literature Review

The literature review begins by describing the contents of the chapter, before addressing the knowledge level about cervical cancer and screening practices (causes, risk factors and early detection) among women, women’s perceptions and attitudes towards cervical cancer and screening practices, the level of cervical screening utilization and whether cervical screening practices vary between rural and urban women, and factors that function as barriers to the utilization of cervical cancer screening practices.

2.6 Theoretical Framework

The bulk of theories applicable to health-related behaviours are mostly based on social and behavioural sciences (National Cancer Institute (NIH), 2005). Theories that have been applied to health promotion, and that will be used in this study include the Health Belief Model (HBM) (Becker, 1974) and the PRECEDE-PROCEED model (PPM) (Green and Kreuter, 1999). Each of these theories explains the factors and processes that influence health related behaviours including cancer screening (Sedigheh, 2012), stopping smoking (Macy et al., 2011), exercise (Gristwood, 2011), and health promotion behaviours in general (Ersin and Bahar, 2011).

Three categories of health behaviour theories are frequently used to predict and explain behaviours at different levels: intrapersonal theories, interpersonal theories, and community/group level models (Esperat et al., 2008). Intrapersonal theories concentrate on the individual's cognitive assessment of health problems and how to resolve them. The interpersonal theories assume that at the interpersonal level, an individual's behaviour and health outcomes are influenced by their interaction with factors within their social and/or physical environment. The community and group level theories concentrate on using social change to explain health behaviours of a population (Esperat, et al., 2008).

The Health Belief Model - The Health Behaviour Model (HBM) is part of the intrapersonal categories of health behaviour theories as it focuses on cognitive and behavioural factors (Esperat, et al., 2008). The authors’ state that the HBM is among the oldest, most frequently used and most reliable models used to explain health behaviours (Esperat, et al., 2008). The HBM has been extensively applied within cervical cancer screening and has been effective in predicting women’s health behaviours (Abotchie and Shokar, 2009).

The HBM was created in the 1950s by social psychologists Rosenstoch, Hochbaum and Kegels (Becker, 1974). It is frequently used to predict preventive health behaviours, and it can explain both individual (Gristwood, 2011) and collective (Glanz et al., 2008) non-engagement with preventive health measures. The HBM is composed of four concepts, namely perceived susceptibility, perceived severity, perceived barriers, and perceived benefits (Glanz, et al., 2008).

Perceived susceptibility occurs when an individual is aware that s/he is susceptible to a potential health problem (such as cervical cancer). When individuals are aware that the health problem may have serious outcomes, this is known as perceived severity. They are likely to take preventive action if they see few obstacles in the way of doing so (perceived barriers) and if they are convinced that the preventive action will minimize the risk, then this is referred to as perceived benefits. These concepts may further influence individual self-efficacy (believing that they have the ability to take preventive action) and action (which may be stimulated by cues to action, such as media adverts or prompting from health professionals) (Glanz, et al., 2008). Although the HBM focuses on the individual, as the individual is the building block of communities and institutions, cervical screening cannot be accomplished only by individual action.

The flaw in the HBM is that it overlooks the influence of interpersonal, social and contextual factors (Glanz, et al., 2008). The interplay between socio-cultural factors affects health behaviours of individuals. Therefore socio-cultural factors have to be taken into account in developing effective cervical cancer screening programs. However, the HBM focuses on one-off individual decisions to participate in preventive health, such as vaccination (Finfgeld, et al., 2003). However, cervical cancer screening may require repeated participation, extending over years, so the HBM may not appropriately describe cervical cancer screening.

The PRECEDE-PROCEED Model (PPM) - The PPM was developed by Green et al., (1980) and it has since grown from a diagnostic tool into a multi-phase model that incorporates environmental health factors and assessments into an intervention process (Green and Kreuter, 2005). The acronym PRECEED within the PRECEDE-PROCEED Model (PPM) stands for Predisposing, Reinforcing and Enabling Constructs in Educational/Environmental, Diagnosis and Evaluation, while PROCEED stands for Policy, Regulatory and Organizational Constructs in Educational and Environmental Development, which concentrates on implementing and evaluating interventions (Crosby and Noar, 2011).

The PPM compensates for the shortcomings of the HBM as it views health promotion from an ecological perspective (Crosby and Noar, 2011). It is an interpersonal model, as health is conceived as a product of individual interaction with the environment (Kok et al., 2004). The PPM applies environmental factors to a community setting (Green and Krueter, 1991), thus it does not view health prevention participation as an individual decision, but instead as a result of environmental forces. Therefore, interventions are aimed at all elements of an individual's environment (including individual behaviour, cognition and skill – Crosby and Noar, 2011) rather than at the individual alone. This allows the health personnel to assess multiple levels of environmental influence and relationships.

While the HBM explains and predicts individual behaviour, the PPM can be used to design an entire preventive health intervention in a community (Crosby and Noar, 2011). Such a planning model can entirely transform health interventions in a community. The PPM is a foundation upon which health behaviour change programs can be built (Green and Kreuter, 1999). The most recent iteration of the PPM is a logical model which aims at identifying the factors which lead to a health outcome (Green and Kreuter, 2005).

This recent version is a streamlined planning model which combines two of the nine phases of the PPM, and allows implementers to skip phases if there is pre-existing evidence (Green and Kreuter, 2005). The PPM applies to a specific community ecological tool to resolve a specific health problem within that community (Crosby and Noar, 2011). The PPM analyses the entire situation, including attitudinal, behavioural and educational problems, the intended outcome, the context of the client, and the identification of potential barriers that could affect the intended outcome. The PPM is multidimensional, as it includes elements of behavioural and social science, administration, education and epidemiology (Green and Kreuter, 2005).

The limitations of the PPM include the fact that it does not consist of testable, falsifiable theories. Instead it facilitates the application of theories to intervention programs (Crosby and Noar, 2011). Indeed, no single theory or conceptual framework governs all practice and research in healthcare (Glanz and Bishop, 2010). Both aspects of the PPM and HBM will be used in the current study to interrogate barriers to cervical cancer and screening practices among women in Uasin Gishu County.


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Barriers to cervical cancer screening practices among women in Gishu County, Kenya
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