Barriers and Facilitators of Cervical Cancer Screening among Women in Marembo Ward, Kitagata Town Council, Sheema District

Technical Summary: Barriers and Facilitators of Cervical Cancer Screening in Marembo Ward, Sheema District

Problem Statement
Despite the availability of cervical cancer screening services in most Ugandan health facilities, uptake remains critically low, with less than 10% of eligible women screened nationally. In the specific context of Marembo Ward, Kitagata Town Council, Sheema District, there is a paucity of data regarding the specific socio-demographic, individual, and institutional factors influencing screening behaviors among women aged 21–65 years. This study addresses the gap in understanding why screening rates remain low in this rural setting, aiming to inform policy and strategies to improve utilization in alignment with World Health Organization (WHO) 2030 elimination goals.

Methodology
The research employed a mixed-methods design utilizing a concurrent triangulation approach, combining quantitative and qualitative data collection in the same phase.

• Study Population: Women aged 21–65 years residing in Marembo Ward.
• Sample Size and Sampling: A quantitative sample of 100 participants was recruited using systematic random sampling from a population frame of 680 eligible women. A qualitative subsample of 10 women (10% of the quantitative sample) was selected via purposive sampling for six Focus Group Discussions (FGDs) to achieve data saturation.
• Data Collection: Quantitative data were gathered using a structured, custom-designed questionnaire administered by research assistants fluent in Runyakitara. Qualitative data were collected through audio-recorded, semi-structured face-to-face interviews and FGDs.
• Data Analysis: Quantitative data were analyzed using SPSS version 26.0, employing descriptive statistics and multiple logistic regression to determine Adjusted Odds Ratios (AOR) at a significance level of p < 0.05. Qualitative data were transcribed, translated, and analyzed using thematic analysis.
• Quality Control: The instrument demonstrated high validity (Content Validity Index = 0.84) and reliability (Cronbach's alpha = 0.78) following pilot testing and refinement.

Key Results

• Screening Uptake: The study found a critically low lifetime screening uptake of 18.0% among participants; 82.0% had never been screened.
• Socio-Demographic Facilitators: Logistic regression identified significant facilitators for screening:
  • Age: Women aged 31–45 were 3.54 times more likely to be screened compared to those aged 21–30 (AOR=3.54, p=0.031).
  • Education: Tertiary education was a powerful predictor, with women 14.20 times more likely to screen than those with primary education or less (AOR=14.20, p<0.001).
  • Employment: Formal employment increased screening odds fivefold compared to peasant farming (AOR=5.11, p=0.029).
  • Marital Status: Contrary to some literature, married/cohabiting women were 58% less likely to screen than single women (AOR=0.42, p=0.038).
• Individual Barriers: Among unscreened women, the primary barriers were:
  • Lack of information (69.0%).
  • Fear of testing positive (62.5%).
  • Fear of pain during the procedure (54.9%).
  • Spousal disapproval (48.2%).
• Health System Barriers:
  • Long waiting hours were cited by 71.0% of respondents as a deterrent.
  • Male health workers performing the test caused discomfort for 61.0% of respondents.
  • Long distance to facilities was a barrier for 53.0%.
  • Logistic regression confirmed that living close to a facility (AOR=3.10, p=0.044) and having a female examiner (disagreeing that male workers were a barrier, AOR=4.64, p=0.013) were significant independent predictors of screening.
• Qualitative Insights: Thematic analysis revealed deep-seated cultural and psychological barriers:
  • Misconceptions: Screening is viewed as a reactive measure for symptomatic illness rather than a preventive tool.
  • Instrument Fears: Exaggerated rumors describe the speculum as a "cold metal iron" that tears flesh, creating panic.
  • Cultural Norms: In the Ankole culture, exposing reproductive anatomy to male clinicians is a profound violation of privacy, causing shame and avoidance.
  • Spousal Dynamics: Husbands often control financial resources and interpret a wife's request for a pelvic exam as a sign of infidelity, effectively sanctioning her mobility.

Key Contributions
The study provides context-specific evidence that cervical cancer screening in Marembo Ward is constrained by a complex interplay of socio-economic disparities, institutional barriers, and cultural norms.

1. Demographic Stratification: It highlights that screening is disproportionately accessed by educated, formally employed women aged 31–45, leaving peasant farmers and younger/older women vulnerable.
2. Gender and Cultural Specificity: It identifies the presence of male examiners as a critical, statistically significant barrier rooted in local Ankole cultural values regarding female privacy.
3. Spousal Influence: It underscores the role of male partners not just as supporters but as gatekeepers who can actively block access through financial control and suspicion of infidelity.
4. Facilitators: It identifies that peer influence (knowing someone with cancer) and integration into antenatal care are key motivators, while the perceived affordability of public services is a primary driver for those who do screen.

Significance and Claims
The authors claim that the low screening uptake is not merely a result of service unavailability but is driven by specific, addressable barriers:

• Systemic Optimization: The study asserts that deploying female examiners is a necessary intervention to overcome cultural shame and improve uptake.
• Policy Integration: It recommends integrating screening education into routine antenatal, postnatal, and family planning clinics to leverage existing health-seeking behaviors.
• Community Sensitization: The authors argue that campaigns must reframe screening as a "protective family health measure" rather than an invasive procedure and must actively engage religious and community leaders to counter misinformation.
• Male Involvement: The paper concludes that interventions targeting women alone are structurally insufficient; addressing spousal dynamics and engaging men is essential to neutralize barriers related to marital suspicion and financial control.

The study concludes that without addressing these specific socio-cultural and institutional constraints, screening rates in rural Sheema District will remain below the WHO 2030 targets.