knowledge attitudes and practices of cervical cancer screening among women who attend traditional churches in zimbabwe

Accepted Manuscript Knowledge, attitudes and practices of cervical cancer screening among women who attend traditional churches in Zimbabwe Julia Mutambara, Phillip Mutandwa, Mildred Mahapa, Vonai Chirasha, Sibusiso Nkiwane, Traquilister Shangahaidonhi PII: S2311-3006(16)30164-1 DOI: 10.1016/j.jcrpr.2017.02.001 Reference: JCRPR 50 To appear in: Journal of Cancer Research and Practice Received Date: October 2016 Revised Date: 26 January 2017 Accepted Date: February 2017 Please cite this article as: Mutambara J, Mutandwa P, Mahapa M, Chirasha V, Nkiwane S, Shangahaidonhi T, Knowledge, attitudes and practices of cervical cancer screening among women who attend traditional churches in Zimbabwe, Journal of Cancer Research and Practice (2017), doi: 10.1016/ j.jcrpr.2017.02.001 This is a PDF file of an unedited manuscript that has been accepted for publication As a service to our customers we are providing this early version of the manuscript The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain ACCEPTED MANUSCRIPT Cover page Knowledge, attitudes and practices of cervical cancer screening among women who attend RI PT traditional churches in Zimbabwe Mutambara Julia1, Mutandwa Phillip2, Mahapa Mildred3, Chirasha Vonai3, Nkiwane Sibusiso2, SC Shangahaidonhi Traquilister3 Department of Behavioural Sciences, Faculty of Medicine, Midlands State University Psychology Department, Faculty of Social Sciences, Midlands State University Human Resources and Management Department , Faculty of Social Science, Midlands State University M AN U AC C EP TE D Corresponding Author- juliamutambara@gmail.com ACCEPTED MANUSCRIPT RI PT Knowledge, attitudes and practices of cervical cancer screening among women who attend traditional churches in Zimbabwe SC Abstract Cervical cancer has led to high mortality rates amongst women in Zimbabwe Some members of Traditional Churches in Zimbabwe (TCZ) view M AN U going to the hospital as unholy, and most of the women who go to these churches may not be allowed to access medical care A cross-sectional study was conducted to ascertain the knowledge, attitudes and practices of cervical cancer screening among these women A self-administered 20 item questionnaire was given to 125 women The results of the study showed that knowledge about factors that caused cervical cancer was relatively high No significant differences were found among the women concerning their feelings towards cervical cancer However, their attitudes towards Pap smear tests were positive in that a large majority of these women (89, 71.2%) acknowledged that they would be worried TE D and seek medical attention if they felt any signs of cancer lesions However, an even larger majority (104, 83.2%) of the women reported not having been screened for cervical cancer The reasons that prevented women from having a Pap smear included: lack of knowledge, belief that cancer was untreatable and religious beliefs that prevented these women from seeking medical care Overall, there is general need to educate EP women especially from traditional churches to pursue cervical cancer screening in Zimbabwe Introduction AC C Key words: cervical cancer, traditional churches, Zimbabwe, knowledge, attitude, practice Cancer of the cervix (CC) is the second most common cancer affecting women worldwide, and about 86% of CC cases occur in developing countries In fact, these cases actually represent approximately 13% of female cancers overall1 Statistically, CC is one of the leading causes of illness and death amongst the gynaecological cancers worldwide, especially in developing countries The American Cancer Society estimated ACCEPTED MANUSCRIPT that of the over 12.000 cases of invasive cervical cancer diagnosed, approximately 3.000 of the women will die from the disease3 Although CC RI PT is considered one of the most preventable cancers 4, most women who seek help for cancer-related illnesses usually so when the disease has advanced, and is no longer treatable The situation in Zimbabwe is largely unknown, particularly given the scarcity of epidemiological data However, it is estimated that 2270 SC women are diagnosed with cancer every year in Zimbabwe, and 1451 die from the disease Cervical cancer is the most frequently occurring cancer among women in Zimbabwe, and the 2nd most frequent cancer among women between 15 and 44 years of age6 There has been an M AN U increase in cancer screening centers in Zimbabwe, but further improvements need to be made as the acceptance rate of this service remains low Early detection is quite crucial for a country like Zimbabwe where treatment services such as surgery, chemotherapy and radiotherapy are frequently unavailable for advanced cervical cancer At the few institutions where these services are in place and available, they are usually very expensive and cannot be afforded by many women7 The Human papillomavirus (HPV) is a sexually transmitted infection, recognized as the cause of 99% of all cervical cancers worldwide8 TE D Women are primarily infected with HPV in their teens, 20s, or early 30s6 Therefore, it is recommended that women should be screened three years after their first sexual intercourse The discovery of the human papillomavirus (HPV) as a predominant cause of cervical cancer has necessitated the administration of HPV vaccines as an additional means of cervical cancer prevention The HPV vaccination has the potential to EP reduce the incidence of cervical cancer worldwide by 70%; the remaining 30% of cancers can be prevented through regular cervical cancer screening 10 Precancerous lesions can be detectable 10 years or more before cancer develops However, it has been noted that many women in AC C developing countries not obtain screening even when the facility is available About 90% of cervical cancer could be prevented if all women were offered and complied with high quality cytological screening programs 11 Papanicolaou cytological testing (Pap smear) allows cervical lesions to be detected before they become cancerous, thereby effectively reducing the incidence of cervical cancer by 75–90% Following a Pap smear there is a need for a colposcopy procedure, which is the standard follow-up for an abnormal Pap smears12 ACCEPTED MANUSCRIPT The risk factors for cervical cancer include early age of first intercourse, multiple sexual partners, HPV virus and HIV infection13,14 In general, RI PT all sexually active women are at risk for developing cervical cancer 15 Non-compliance with screening guidelines continues to be a major risk factor for invasive cervical cancer 16 Family history of cervical cancer, early sexual activity, age, lack of regular Pap smear testing, as well as number of pregnancies are also risk factors for CC Studies have found that there was a strong interplay between the knowledge and attitudes of SC CC and the resultant health seeking behaviours 17,18.Women`s attitudes towards cervical cancer screening have been found to have an impact on the adoption of cervical cancer screening in many developing countries A study in Thailand found that female sex workers with negative M AN U attitudes about Pap smear services were less likely to have ever had a cervical smear taken than those with a positive attitude19 Most women were found to be unaware of possible prevention of the disease, including screening services for early detection and treatment of precancerous lesions20 Some women affected by CC tend to initially seek treatment from traditional healers and use holy water 17,21 Beliefs concerning the cause of the disease are a crucial determinant of subsequent healthcare-seeking behavior Factors that predict underutilization of cervical cancer screening include older age, lower educational attainment, lower socio-economic status, single marital status, rural residence and TE D negative health and lifestyle characteristics such as infrequent physical activity and not having a regular family doctor 22 Pap smear screening among women has been found to be limited by a lack of knowledge about Pap smears and their importance, feelings of embarrassment and a lack of continuity of care due to a high turnover of health professionals22 EP Traditional churches in Zimbabwe discourage women from seeking medical attention as they urge them to have faith and receive their healing AC C from God However, the prevalence of cervical cancer among women attending traditional churches in Zimbabwe has not been established The traditional churches (Apostolic Churches) that were the focus of this study have an indigenous origin, with their founders being local Zimbabwean people Correspondingly, they have practices that are quite similar to traditional cultural practices Most of these churches not allow members to seek medical care These Apostolic churches emphasize faith healing and strict adherence to church beliefs and practices, which undermine the benefits of modern health care For these women, seeking medical care may result in sanctions like confession, shaming, or ACCEPTED MANUSCRIPT a prohibition from wearing church regalia or undergoing rebaptism These churches believe that illness is caused by evil spirits, and that healing RI PT is conducted by prophets and other spiritual leaders23 Methods SC This cross –sectional study was conducted from September - October 2015 among females who attend traditional churches in Gweru in the Midlands Province of Zimbabwe M AN U Sample The study sample was selected randomly Statistics on the total number of women who attend different traditional churches in Gweru are not known As such, the different strata were made up of the various church denominations attended by these women Snowball sampling and convenience sampling were used to select women within the strata Access to administer the questionnaire to study participants was sought from participated in the study TE D the leaders of the various denominations after explanation of the purpose of the study Individual consent was sought from all women who EP One hundred twenty-five (125) women participated in this study, who were mainly from the Shona and Ndebele tribes in Zimbabwe The Shona tribe is the largest group of people in Zimbabwe, and includes a population that may speak more than five dialects Their numbers are estimated AC C to exceed million, represent over 80% of the population and are the most culturally dominant tribe in the country The Ndebele tribe is a minority in the country, and originated from South Africa Data analysis ACCEPTED MANUSCRIPT A questionnaire was used to collect data on the women`s knowledge, attitudes and practice of cervical cancer screening The questionnaire had RI PT four sections: 1) Section A- demographic data; 2) Section B was a questionnaire focusing on respondent knowledge; 3) Section C was a questionnaire about respondent attitudes; and 4) Section D, which was a questionnaire asking about practices Variables were stratified as follows: age (less than 35 years vs 35 years and older), education (13 years of education or more vs less than 13 SC years of education) and marital status (married or living with a partner vs not married or living with a partner) Descriptive statistics was used in M AN U this study and SAS version 9.2 was used for statistical analysis Results Table Socio-demographic characteristics of women who participated in the study Age 18-29 Tribe group 30-39 40-58 Shona Level of Education Ndebele Others Specify Tertiary % 33.6 49 34 73 39.2 27.2 58.4 42 10 12 33.6 8.0 9.6 Primary Secondary Other Married 22 80 11 67 17.6 64.0 8.8 53.6 Not married Widow Separated Divorced 22 13 17 17.6 10.4 13.6 4.8 EP TE D 42 AC C Marital status count ACCEPTED MANUSCRIPT N= 100.0 RI PT 125 As shown in Table above, the study participants were between 18 - 58 years of age, with the mean age group being 38 years The ages of the participants were distributed as follows – The majority of the participants (49) were in the age range 30-39, with 42 participants in the age group SC 18-29) and 34 participants in the 40-45 years category Most of the participants were from the Shona ethnic group (58.4%) In terms of academic qualifications, 80 women had secondary education (form 1-4), 22 had attained primary level grade (1-7), and 11 had tertiary qualification (post M AN U secondary qualification - certificate, diploma, etc) Twenty-two women were not married, 17 were separated, 13 widowed and divorced Table 2: Knowledge about cervical cancer What is a Pap smear test? Tribal group Level of education 30-39 40-58 Sh N other Correct responses 26 62% 18 37% 12 35% 38 52% 12 29% 60% Wrong responses 16 38% 31 69% 22 65% 35 48% 30 71% 40% AC C What is cervical cancer Pri Sec Other Mrd N.Mrd W Sp Drv 58 % 42 % 36% 38 46% 27% 31 46% 12 56% 38% 24% 67% 14 64% 42 54% 73% 36 54% 10 44% 62% 13 76% 33% 18% 18 82% 27 34% 53 66% 9% 10 91% 20 30% 47 70% 23% 17 67% 31% 69% 24% 13 76% 50% 50% 16 73% 27% 66 83% 14 17% 64% 36% 57 85% 10 15% 19 86% 14% 10 77% 23% 41% 10 59% 100% 0% Correct 12 15 19 13 4 29% 31% 26% 26% 31% 40% 33% responses 30 34 25 54 29 Wrong 79% 66% 74% 74% 69% 60% 27% responses Cervical cancer is the second highest cause of cancer death for women in Zimbabwe Correct responses Wrong responses 34 81% 19% 38 78% 11 22% 27 79% 21% 63 86% 10 14% 30 71% 12 29% 60% 40% Marital status Ter EP 18-29 TE D Age 10 83% 17% ACCEPTED MANUSCRIPT How often does a doctor/nurse recommend for women to come and have a pap smear 19 45% 23 55% 24 49% 25 51% 15 44% 19 56% 33 45% 40 55% 22 52% 20 48% 30% 70% 75% 25% 11 50% 11 50% 38 48% 42 52% 55% 45% 33 49% 34 51% 41% 13 59% 38% 62% 47% 53% 50% 50% 22 28% 58 72% 0% 11 100% 15 22% 52 78% 32% 15 68% 0% 13 100 % 6% 16 94% 33% 67% Correct responses Wrong responses 13 31% 29 69% 16% 40 84% 12% 30 88% 14 19% 59 81% 10 24% 32 76% 10% 90% 10 83% 17% 14% 19 86% Correct responses 33 79% 43 88% 25 74% 59 81% 33 79% 90% 67% 20 91% Wrong responses 21% 14% 26% 14 19% 21% 10% 33% 9% Do you think that when cervical cancer is detected early in its course, it can be treated 31 74% 11 26% 30 61% 19 39% 22 65% 12 35% 51 70% 22 30% 27 64% 15 36% 50% 50% 50% 50% 14 64% 36% 66 83% 64% 52 78% 18 82% 10 77% 15 88% 14 17% 36% 15 22% 18% 27% 12% 100 % 0% 53 66% 27 34% 10 91% 9% 48 72% 19 23% 14 64% 36% 46% 54% 10 59% 49% 83% 17% TE D Correct responses Wrong responses M AN U What increases the risk of cervical cancer SC At what age is a women most likely to have cervical cancer RI PT Correct responses Wrong responses EP Table above shows that there was variation in knowledge among these women The majority (62%) of individuals of ages 18-29 and 38 (52%) of Shona tribe women had above average knowledge regarding the nature of a Pap smear test However, 42 (54%) women with a secondary level AC C qualification were not aware of the Pap smear test, accompanied by 36 (54%) married women in the study Women of ages 18-29 (79%), 3039(66%), 40-58(74%), Shona (74%), Ndebele (69%), other tribes (60%), tertiary (27%), 82% with primary level education, 66% with secondary level education and 91% with other qualification presented with a poor understanding of cervical cancer Most of the women presented average to above average knowledge on recommended periodic screening for cervical cancer ACCEPTED MANUSCRIPT The majority of women in this study did not know the age at which the likelihood of developing cervical cancer increases, which included 29 RI PT (69%) women in the 18-29 group, 40 (84%) of ages 30-39, 30 (88%) in the 40-58 group, 59 (81%) of Shona, 32 (76%) of Ndebele, (90%) of other minority tribes, 12 (100%) with a tertiary education, 19 (86%) with a primary education, 58 (72%) with secondary education, 11 (100%) with other academic qualification, 52 (78%) married, 15 (68%) not married, amongst the widowed 13 (100%), and 16 (94%) and (67%) in the SC separated and divorced, respectively However knowledge about factors that caused cervical cancer was relatively high; the majority (79%, 88% and 74%) of women of ages 18-29, 30-39 and 40-58, respectively, knew what caused cervical cancer Such figures were identified with 59 (81%) of the Shona, 33 (79%) Ndebele, and (90%) from other minority clans, (67%) with tertiary qualification, 20 (91%) with primary level M AN U education, a significant 66 (83%) with secondary education, (64%) with other academic qualifications, 52 (78%) married, 18 (82%) unmarried, 10 (77%) widowed, 15 (88%) separated and (100%) divorced, exhibiting significant knowledge about what enhanced the chances of developing cervical cancer as shown above in Table Further evidence demonstrated relative to above average knowledge regarding how early treatment influences the progression or course of TE D cervical cancer development There were 74%, 61% and 65% of women of ages 18-29, 30-39 and 40-58, respectively, who knew the importance of early intervention Furthermore, 70%, 64% and 50% of women of the Shona, Ndebele and other tribes had knowledge about how early intervention could positively impact the course of cervical cancer development Six participants with a tertiary education, 64% primary, 66% AC C about the importance of early intervention EP secondary, 91% other academic qualification, 72% married, 64% not married, 46% widowed, 59% separated and 83% divorced had knowledge Table Demographic characteristics vs knowledge Knowledge about cervical demographics Age group Tribal group Level of education Marital status ACCEPTED MANUSCRIPT 30-39 40-58 Shona Ndebele Other Tertiary Primary Secondary Other Married Not Married Widowed Separated Divorced High knowledge 23 (55%) 24 (49%) 16 (47%) 40 (55%) 21 (50%) (50%) (41.5%) 11 (50%) 41 (51%) (45%) 37 (55%) 12 (54%) (46%) (41%) (67%) Moderate knowledge (14%) (18%) (18%) 11 (15%) (14%) (20%) (16%) (23%) 12 (15%) (27.5%) 12 (18%) (14%) (15%) (18%) (16.5%) Low knowledge 13 (31%) 16 (33%) 12 (35%) 22 (30%) 15 (36%) (30%) (41.5%) (27%) 27 (34%) (27.5%) 18 (27%) (32%) (39%) (41%) (16.5%) SC N = 125 RI PT 18-29 M AN U As shown in Table above, 55% of those women in the 20-29 years old category had high knowledge regarding cervical cancer screening Also, 55% of the Shona and 50% of the Ndebele had high knowledge of cervical cancer screening Additionally, 55% of the married women and 67% of the widowed women had high knowledge of cervical cancer screening Fifty-one percent of those women with primary education and 51 % of those with secondary education had high knowledge of cervical cancer This indicated that knowledge levels did not differ significantly with Hn Do you feel embarrassed when undergoing a Pap smear Age group AC C Positive responses Tribal group EP Table Attitudes towards cervical cancer screening TE D level of education Level of education Marital status 18-29 30-39 40-58 Sh N Other Ter Pri Sec Other Mrd N.Mrd W Sp Drv 23 (55%) 25 (51%) 18 (53%) 41 (56%) 19 (45%) (60%) (50%) 10 (45) 47 (59%) (27%) 40 (60%) 12 (55%) (62%) (24%) (33%) ACCEPTED MANUSCRIPT 19 (45%) 24 (49%) P-Value 16 (47%) 32 (44%) 23 (55%) (40%) 0.996 (50%) 12 (55%) 33 (41%) 0.371 22 (45%) 19 (56%) 31 (42%) 26 (62%) (30%) (33) 12 (55) Negative responses 23 (55%) 27 (55%) 15 (44%) 42 (58%) 16 (38%) (70%) (67%) 10 (45) 0.080 Going for a Pap smear is expensive 28 (67%) 28 (57%) 26 (76%) 56 (77%) 27 (64%) Negative responses 14 (33%) 15 (43%) (24%) 17 (23%) 15 (36%) 0.143 (50%) 10 (45%) (38%) 13 (76%) 41 (51%) (58%) (42%) (67%) 0.081 (45) 34 (51%) (36%) (67%) (35%) (67%) (55%) 33 (49%) 14 (64%) (33%) 11 (65%) (33%) 0.834 0.197 17 (77%) 57 (71%) (64%) 42 (63%) 18 (82%) 10 (78%) 13 (76%) (83% (23%) 23 (29%) (36%) 25 (27%) (18%) (22%) (24%) (17%) 0.162 0.766 0.414 EP P-Value (50%) TE D Positive responses 39 (49%) SC 19 (45%) M AN U Positive responses 0.699 27 (40%) 0.182 Do you feel more comfortable undergoing a Pap smear test if the doctor/nurse is male or female P-Value (73%) RI PT Negative responses AC C I would be worried if I was to have early signs of cancer (pre-cancer lesions) Positive responses 29 (69%) 35 (71%) 25 (74%) 55 (75%) 25 (60%) (90%) 11 (92%) 12 (55%) 59 (74%) (64%) 47 (70%) 15 (68%) (62%) 14 (82%) (83%) Negative responses 13 (31%) 14 (29%) (26%) 18 (25%) 17 (40%) (10%) (8%) 10 (45%) 21 (26%) (36%) 20 (30%) (32%) (38) (18%) (17%) P-Value 0.177 0.078 0.113 0.711 10 ACCEPTED MANUSCRIPT 36 (49%) 37 (51%) 26 (62%) 16 (38%) (60%) (40%) 0.405 (58%) (42%) 10 (45%) 12 (55%) (64%) (36%) 0.766 39 (61%) 28 (39%) 13 (59%) (41%) (23%) 10 (77%) 11 (65%) (35%) (33%) (67%) 0.111 SC (n=125) 44 (55%) 36 (45%) RI PT My religion does not allow me to go for a Pap smear 26 28 14 Positive (62%) (57%) (41%) responses 16 21 20 Negative (38%) (43%) (59%) responses P-Value 0.913 There were no significant differences between and within different groups of women in expressing feeling towards having a Pap smear as M AN U highlighted by the ANOVA tests The P-value on age was 996; tribal group experiences 371, level of education 182 and marital status 081 Furthermore, the majority reported varied experiences when the health care provider performing the Pap smear was male or female Thus, women with positive attitudes towards Pap smear tests were those who did not discriminate undergoing the tests based on the gender of the health care provider Hence, the majority of women who were affected by the gender of the health care provider were those between ages 30-39 of both tribes Moreover, most women (51.25%) with a secondary education were significantly affected by the gender of the health care provider TE D in deciding whether or not they would have a Pap smear, which was further underscored by the fact that the majority (45.6%) of these women were married No significant differences between and within groups in the experience were identified as shown by the following P-values: age = 699, tribal group = 080, level of education = 834 and marital status = 197 EP The majority of women of all ages agreed that the Pap smear test was not very expensive; this understanding was shared by all women in different tribes, educational levels and marital statuses Therefore, of the 125 women participants, 104 (83.2%) had never undergone a Pap AC C smear However, the attitude towards Pap smear tests was positive, with the majority 89 (71.2%) of women acknowledging that they would be worried and seek medical attention if they felt any signs of cancerous lesions However, most of the women in TCZ shared the same perspective, as no significant difference between and within these groups of individuals were noted with the P-value of age = 117, tribal group = 078, level of education = 117 and marital status = 711 above the level of significance Further evidence illustrated that religion shaped the decisions that 11 ACCEPTED MANUSCRIPT smear test if the need ever rose Table Practice of cervical cancer screening 30-39 40-58 Sh N Other 11 34 42 28 62 33 0.826 Do you think screening centres are accessible 18 15 14 Positive practices 24 34 20 Negative practices P-Value 0.434 What was the last time you had a pap smear 13 Positive practices 34 36 25 Negative practices 47 27 26 15 Pri Sec 46 Mrd N.Mrd W Sp Drv 14 13 10 20 66 54 20 12 13 0.617 0.640 14 51 45 13 10 29 22 0.822 27 Other TE D Do you think undergoing a pap smear is painful 29 30 22 Positive practices 13 19 13 Negative practices P-Value 0.963 0.574 Ter Marital status SC 18-29 0.696 0.466 17 54 10 24 25 15 26 43 13 11 EP P-Value Level of education AC C Positive practices Negative practices Tribal group M AN U Were you ever screened for cervical cancer Age RI PT most of these individuals made; however, the majority (54.4%) highlighted that they would disregard religious influence and go for the Pap 0.820 0.002 0.962 17 13 19 18 56 29 10 17 61 49 17 10 15 12 ACCEPTED MANUSCRIPT 0.938 0.232 0.580 33 24 20 47 43 13 13 0.044 0.324 SC Do you have an intention of going for a pap smear test within the next years 16 17 26 12 Positive practices Negative 24 32 25 47 30 practices P-Value 0.655 0.128 0.854 RI PT P-Value (n=125) M AN U Although most of the women (56%) of TCZ indicated that they possessed an intense knowledge about cervical cancer and Pap smear test, their responses towards Pap smear tests were in direct conflict with practices regarding prevention of cervical cancer as shown in Table above Age, tribal group, level of education and even marital status did not positively influence practices regarding cervical cancer treatment The majority (104, 83.2%) of the women reported not having been screened for cervical cancer Moreso, 69% of the women reported that Pap smear tests were not scary or painful, and as such were willing to go for one However, this was contradicted by the majority 78 (62.4%), who proposed that TE D tests or testing centres were not accessible and this significantly affected their decision to go for Pap smear tests However, significant differences in practices were recorded based on the level of education, which indicated that as women achieved more education, the greater the chances of making an effort to access cervical cancer testing centres, where P-value = 0.002 (P ˂ 0.05) Furthermore, 95 (76%) of the women EP reported no Pap smear test within the past three years, with others reporting never undergoing a Pap smear Findings from our study further Discussion AC C demonstrated that most of the women (83, 66.6%) had no intention or doubted if they would go for a Pap smear test in the following year The findings revealed that TCZ women had significant knowledge regarding cervical cancer, although variations in their knowledge levels were noted based upon age, tribal group, level of education and marital status The level of knowledge was high in the 18-29 age group, those women in the Shona tribe, and those with a secondary level education and married This directly contrasted with that study which revealed a deficiency 13 ACCEPTED MANUSCRIPT in knowledge amongst women with a secondary education24 Such findings demonstrated that, with the prevailing age of information RI PT technology, most individuals ages 18-29 have a high probability of accessing information about cervical cancer and other related diseases On the other hand, most married couples had an opportunity to make frequent hospital and clinical visits, exposing them to medical literacy and information about cervical cancer This information access was coupled with the general availability of knowledge and intellectual development SC that allowed people in secondary school levels to become educated about reproductive health, a circumstance that allowed development of knowledge regarding cervical cancer Therefore, women who had the least chance of accessing educational facilities had an elevated chance of possessing low knowledge regarding cervical cancer Such findings disputed the notion that women from TCZ did not have knowledge in M AN U regards to cervical cancer and heavily relied on traditional healers if they had any problems17, 19 The findings revealed that TCZ women of 18-29 years of age had knowledge about the nature of Pap smear as compared to other categories, and they also knew that if cervical cancer was detected early, medication and other early forms of interventions could be initiated to deal with the problem before it progressed Additionally, they had high knowledge about the fact that cervical cancer was the second largest killer among the institutions in Zimbabwe is US$525 TE D female population Most of the women were aware that a Pap smear procedure was inexpensive; in fact, the cost of a Pap smear in public health EP However, the participants had low to relatively no knowledge about the nature of cervical cancer, and the age at which they could become prone to developing cervical cancer Furthermore the 18-29 age groups was not familiar with the period when women had to go for physical check-ups AC C for cervical cancer Similar findings were found regarding the influence of the tribe on knowledge of cervical cancer The Shona women had high knowledge about the nature of a Pap smear test, and they also knew that cancer was the second highest killer of women compared to HIV The participants were aware that if early interventions were made, treatment could reduce the chances of disease progression Significant knowledge levels of factors that would cause development of cervical cancer were noted in women of all groups and tribes Overall, the divorced women had an average to above average knowledge regarding cervical cancer, and were likely to visit doctors for assistance as indicated by 14 ACCEPTED MANUSCRIPT knowledge about when they were supposed to initiate testing for cervical cancer RI PT average to above average score regarding knowledge about cervical cancer Women of all ages had challenges concerning the extent of their Most women did not experience embarrassment undergoing a Pap smear test However, most also reported that the gender of the health provider to carry out the Pap smear test had a significant influence on how they perceived the test Such evidence literally brings out the underlying SC element of embarrassment that women felt if the doctor was either male or female The majority of the women in all categories believed that the test was not expensive, and were ready to have a cervical cancer check-up if they suspected precancerous lesions Moreover, the majority of the M AN U women stated that religion would not affect their capacity to seek medical attention if the need arose, except for women between the ages of 4058, those from the Shona tribe, those with a primary education and those either widowed or divorced Although the knowledge and attitudes of these TCZ women were relatively high and positive towards understanding the development and treatment of cervical cancer, their practices involving the prevention of cervical cancer were poor Thus, their age, tribe, level of education and TE D even marital status did not have a positive influence on practices regarding the prevention of cervical cancer Such findings concurred with the study publicized by Al-Meer et al on female teachers in Sharjah in the United Arab Emirates; these women had significant knowledge about Pap smear but did not commonly practice it24 A study about the factors affecting attitudes toward colorectal cancer screening found that ethnicity AC C EP had an impact on screening Interestingly, black-Caribbean participants showed greater intentions to get screened compared to white respondents 26 The research suggested that negative attitudes towards screening were influenced by culture Although some studies have shown that positive attitude may result in an improved participation in screening 19, a study in Niger among market women revealed that although there was a good attitude towards cervical cancer screening (80.4%), their level of practicing such screening was low (15.4%)27 15 ACCEPTED MANUSCRIPT In this study, we had confirmed that the majority of women in TCZ had not been screened for cervical cancer, and a significant portion of the RI PT population was influenced by the belief that Pap smear tests were frightening and painful to indulge Research evidence has shown that noncompliance with cervical cancer screening has been the predominant problem among women in various contexts despite their age, tribe, level of education and marital status16 Studies have indicated that knowledge about cervical cancer, and utilization of that knowledge should be accompanied by courage, confidence and wisdom regarding when and how to apply such an understanding to help combat a very persistent M AN U SC cervical cancer problem 28 Conflict of interest EP TE D None AC C WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre): Human Papillomavirus and Related Cancers in Nigeria.In Summary Report 3rd edition 2010 Accessed 2nd August, 2010 at www.who.int/hpvcentree Ali SF, Ayub S, Manzoor NF, et al Knowledge and awareness about cervical cancer and its prevention amongst interns and nursing staff in tertiary care hospitals in Karachi, Pakistan PLoS ONE, 5(6) doi:10.1371/journal.pone.0011059, 2010 16 ACCEPTED MANUSCRIPT American Cancer Society [Internet] 2009 [Cited 2016 July 9] Do we know what causes cervical cancer? Available from: RI PT http://www.cancer.org/docroot/CRI/content 242x: 2009 Pontin J, Adami HO, Bergstrom R, et al Strategies for global control of cervical cancer Int J Cancer, 60(1), 1–26, 1995 Laikangbam P, Sengupta S, Bhattacharya P, et al A comparative profile of the prevalence and age distribution of human papillomavirus SC type 16/18 infections among three states of India with focus on northeast India Int J Gynecol Cancer, 17, 107–117, 2007 ICO Information Centre on HPV and Cancer Zimbabwe Human Papillomavirus and Related Cancers, Fact Sheet 2016[Internet] [Cited 2016 November 1] Available from: http://www.hpvcentre.net/statistics/reports/ZWE_FS.pdf Why get checked for cervical cancer http://zimbabwe.unfpa.org/fr/node/3711 2016 [Internet] M AN U UNFPA [Cited 2016 November 1]Available from: Alliance for Cervical Cancer Prevention (ACCP): Planning and Implementing Cervical Cancer Prevention and Control Programs: A Manual for Managers Seattle, 24-28, 2004 TE D Walboomers JM, Jacobs MV, Manos MM, et al Human papillomavirus is a necessary cause of invasive cervical cancer worldwide J Pathol, 189(1), 1999 10 Cerigo H., Macdonald, ME , Franco, EL & Brassard,P Inuit women’s attitudes and experiences towards cervical cancer and prevention EP strategies in Nunavik, Quebec Int J Circumpolar Health, 71, 2012 DOI: 10.3402/ijch.v71i0.17996 11 The national breast and cervical cancer early detection program Atlanta, Centres for Disease Control and Prevention, US Department of AC C Health and Human Services, 1995 12 Peto J, Gilham C, Fletcher O, Matthews FE The cervical cancer epidemic that screening has prevented in the UK Lancet, 364, 249-256, 2004 13 Bergstrom R, Sparen P, Adami HO Trends in cancer of the cervix uteri in Sweden following cytological screening Brit J Cancer, 81(1), 159–166, 1999 17 ACCEPTED MANUSCRIPT women Nurs Outlook, 45(1), 16–22, 1997 RI PT 14 Arevian M, Naureddine S, & Kabakian T A survey of knowledge, attitude, and practice of cervical screening among Lebanese/American 15 Ndikom CH, Ofi BA Awareness Perception and factors affecting utilization of cervical cancer screening services among women in Ibadan, Nigeria: a qualitative study Reproductive Health, 9-11, 2012 SC 16 Maxwell CJ, Bancej CM, Snider J, Vik SA Factors important in promoting cervical cancer screening among Canadian women: findingsfromthel996-97NationalPopulationHealth Survey (NPHS) Can J Public Health, 92(2), 127-133, 2001 Health, 11, 2012 doi:10.1186/1475-9276-11-83 M AN U 17 Birhanu, Z., Abdissa, A., Belachew, T., et al Health seeking behavior for cervical cancer in Ethiopia: a qualitative study Int J Equity 18 Saha A, Chaudhury AN, Bhowmik P, Chatterjee R Awareness of cervical cancer among female students of premier colleges in Kolkata, India Asian Pac J Cancer Prev, 11, 1085–1090, 2010 19 Chumnan K, Yupin P, Kriangsak J, Usanee S, Jatupol S: Knowledge, awareness and attitudes of female sex workers toward HPV TE D infection, cervical cancer, and cervical smears in Thailand Int J Gynaecol Obstet, 107, 216-219, 2009 20 Coleman MA, Levison J, Sangi-Haghpeykar H HPV vaccine acceptability in Ghana, West Africa Vaccine, 29, 3945–3950, 2011 21 Mutyaba T, Faxelid E, Mirembe F, Weiderpass E Influences on uptake of reproductive health services in Nsangi community of Uganda EP and their implications for cervical cancer screening Reprod Health, 4, 4-9, 2007 94(3), 36-41, 1998 AC C 22 Clarke HF, Joseph R, Deschamps M, Hislop TG, Band PR, Atleo R Reducing cervical cancer among First Nations women Can Nurse 23 UNICEF Apostolic religion, health and utilization of maternal and child services in Zimbabwe (2011) [Internet] [Cited 2016 November 2] Available from:https://www.unicef.org/zimbabwe/ZIM_resources_apastolicreligion.pdf 24 Al-Meer FM., Aseel, MT., Al-Khalaf, J., Al-Kuwari, MG & Ismail MFS Knowledge, attitude and practices regarding cervical cancer and screening among women visiting primary health care in Qatar East Mediterr Health J, 2, 2011 18 ACCEPTED MANUSCRIPT :http://www.herald.co.zw/agony-of-cervical-cancer-patients/ RI PT 25 Murombedzi C Agony of cervical cancer patients (2012) [Internet] [Cited 2016 November 2] Available from 26 Taskila T, Wilson S, Damery S, et al Br J Cancer 2009 Jul 21; 101(2): 250–255 Published online 2009 Jun 23 doi: 10.1038/sj.bjc.6605130 PMCID: PMC2720207 27 Ahmed, SA, Sabitu K., Idris, SH, Ahmed R Knowledge, attitude and practice of cervical cancer screening among market women in SC Zaria, Nigeria Niger Med J., 54(5), 316–319, 2013 doi: 10.4103/0300-1652.122337 28 Deschamps M, Band PR, Hislop TG, Clarke HF, Smith JM, To YN Barriers to cervical cytology screening in native women in British AC C EP TE D M AN U Columbia Cancer Detect Prev, 16, 5- 9, 1992 19 ... cancer screening among women who attend traditional churches in Zimbabwe SC Abstract Cervical cancer has led to high mortality rates amongst women in Zimbabwe Some members of Traditional Churches in. .. MANUSCRIPT Cover page Knowledge, attitudes and practices of cervical cancer screening among women who attend RI PT traditional churches in Zimbabwe Mutambara Julia1, Mutandwa Phillip2, Mahapa... from traditional churches to pursue cervical cancer screening in Zimbabwe Introduction AC C Key words: cervical cancer, traditional churches, Zimbabwe, knowledge, attitude, practice Cancer of the