University of South Carolina

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Theses and Dissertations

2018

Assessment Of An Educational Intervention To Increase

Knowledge And Intention To Take HPV Vaccine And Cervical
Cancer Screening In Nigeria
Chigozie Anastacia Nkwonta
University of South Carolina

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To Take HPV Vaccine And Cervical Cancer Screening In Nigeria. (Doctoral dissertation). Retrieved from
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 ASSESSMENT OF AN EDUCATIONAL INTERVENTION TO INCREASE
KNOWLEDGE AND INTENTION TO TAKE HPV VACCINE AND CERVICAL
CANCER SCREENING IN NIGERIA

by

Chigozie Anastacia Nkwonta

Bachelor of Nursing Science

Madonna University, 2008

Master of Nursing Science

University of Ibadan, 2013

Submitted in Partial Fulfillment of the Requirements

For the Degree of Doctor of Philosophy in

Nursing Science

College of Nursing

University of South Carolina

2018

Accepted by:

DeAnne K. Hilfinger Messias, Major Professor

Tisha Felder, Committee Member

Nathaniel Bell, Committee Member

Kathryn Luchok, Committee Member

Cheryl L. Addy, Vice Provost and Dean of the Graduate School

© Copyright by Chigozie Anastacia Nkwonta, 2018
All Rights Reserved.

ii
 DEDICATION

I dedicate this dissertation to my Dad, Mum, sisters and brother. It has been a long,

arduous journey, but finally I can see the light at the end of the tunnel. To my Dad who has

always been my cheerleader and my champion. He told me that the world is my oyster and

I can achieve whatever I set my mind. To my Mum, for challenging me to succeed against

all odds. To my sisters Tochi, Chidiebere, and Onyinye, they have been my backbone and

life support throughout my career. To my baby brother, you have always reminded of my

responsibilities.

iii
 ACKNOWLEDGEMENTS

First of all, I would like to thank the Almighty God for everything he gave me; and

Our Lady of Perpetual help, for her immeasurable love and intersection. I would like to

present many appreciation and thanks to the members of my doctoral committee, for their

unique advice, guidance, support, and unwavering encouragement. Specifically, I would

like to thank my mentor and dissertation chair, Dr. DeAnne Messias for her steadfast

commitment and encouragement and confidence in me. Her dedication, enthusiasm, and

support greatly influenced the success of this dissertation. Also, my committee members,

Dr. Tisha Felder, Dr. Kathryn Luchok and Dr. Nathaniel Bell, their unique expertise was

immeasurably helpful throughout this research process. Without their guidance and

feedback, this dissertation research would not have been possible. I would like to

acknowledge Dr. Cynthia Corbett whose time, suggestions and effort in reading and re-

reading my manuscripts allowed this project to come to this successful conclusion. I would

also like to thank the faculty and staff in the College of Nursing. This research is truly the

result of the collaborative efforts of so many great individuals, each contributing in a

significant way.

I am blessed to have the wonderful support of Dr. Helen Halasz. I am extremely

grateful for her constant love, kindness, encouragement and guidance throughout this

program. With her, I was able to smoothly and successfully navigate the educational and

cultural differences. I also owe heartfelt thanks and gratitude to Dr. Bernadino Pinto for

her support, guidance, mentorship, and, most importantly, commitment to me and my

iv
education. I am so grateful to Dr. Abbas Tavakoli, Dr. Kindred Madison and Miss Wilma

J. Sims, for their statistical expertise and willingness to offer their time, and suggestions to

work with me through this often-treacherous process. I think it is imperative to mention

the person who originally inspired my interest in research. Thank you Dr. Modupe

Oyetunde for encouraging me to pursue a career in research and a research project on

gynecological cancer. Many thanks to the participants in this study, for without you, this

would not be possible.

I was fortunate to have received generous financial support throughout my doctoral

program from the University of South Carolina. I would like to thank the College of

Nursing for funding through the Dean's Doctoral Fellowship Award, Dean's PhD

Scholarship Award and Myrtle Irene Brown Fellowship, and the Graduate School for the

Student Travel Grants. I would like to thank the Women and Gender Studies Department

for funding through the Harriott Hampton Faucette Award which allowed me to travel to

Nigeria to conduct my research.

I am truly indebted to my loving and supporting husband, parents, siblings, nieces,

nephews, aunts, uncle and brother in-laws. Thank you for believing in me and for your

unceasing love and support, I love you all wholeheartedly. I also want to thank my friends,

Mayomi, Otega, Bennie, Erik and Donaldson, for knowing me and loving me through and

through. To each and every individual who believed in and supported me throughout this

journey, I want to say thank you from the bottom of my heart. None of this would have

been possible without your confidence in me, continuous love and support.

v
 ABSTRACT

Nigeria has some of the highest rates of cervical cancer morbidity and mortality in

sub-Saharan Africa. Both the human papillomavirus vaccine (HPV) and cervical screening

are effective prevention strategies against both HPV infection and cervical cancer. Lack of

awareness, limited knowledge, limited decision-making agency, lack of spousal support

and stigma are barriers to uptake of these preventive measures. Given patriarchal structures

and norms through which men control family resources and dominate decisions, male

involvement in initiatives aimed at improving sexual and reproductive health is necessary.

Community-based health education is an effective intervention to improve knowledge and

reduce stigma. The aim of this research was to evaluate the impact of an

educational intervention on awareness, knowledge, intention to take HPV vaccination and

cervical screening, and reduce stigma among men and women offered at 12 urban

community locations in Nigeria. This is a pre-test and post-test study that employed two

community-based health education interventions; a face-to-face presentation delivered in

group settings and printed pamphlet delivered to individuals. A total of 266 participants

within 18 and 65 years participated.

At baseline, the majority (80%) of all participants had low levels of knowledge of

HPV and HPV vaccine and 21% had limited knowledge of cervical cancer and cervical

screening. The proportion of participants with poor knowledge of HPV and cervical cancer

reduced significantly at post-intervention in both groups. Our results showed that less than

12% of all participants had ever received HPV vaccine and screening. There was

vi
significant increase in the participants’ intention to take and to encourage a family member

to receive HPV vaccination and cervical cancer screening. Of note, knowledge of HPV as

a sexually transmitted infection was associated with high levels of stigma, which increased

after exposure to the intervention.

The research supported the effectiveness of the community-based educational

intervention in promoting the increasing awareness, knowledge and intention to take HPV

vaccine and cervical screening among urban-dwelling Nigerian adults. Study findings are

important for informing future gender-comprehensive and context-specific programs

activities that seek to engage men in reducing HPV infection and cervical cancer in Sub-

Saharan Africa. Further research is warranted to assess the factors contributing to ongoing

stigma and to develop effective interventions to reduce stigma among Nigerian adults.

vii
 TABLE OF CONTENTS

DEDICATION…………………………………………………………………………....iii

ACKNOWLEDGEMENTS………………………………………………………..……..iv

ABSTRACT………………………………………………………………………….......vi

LIST OF TABLES……………………………………………………………………......ix

LIST OF FIGURES……………………………………………………………………....xi

LIST OF ABBREVIATIONS………………………………………………………..….xii

CHAPTER 1: INTRODUCTION…………………………………………………………1

CHAPTER 2: MALE PARTICIPATION IN REPRODUCTIVE HEALTH

INTERVENTIONS IN SUB-SAHARAN AFRICA: A SCOPING REVIEW…….……..16

CHAPTER 3: EFFECT OF A COMMUNITY-BASED EDUCATIONAL

INTERVENTION ON AWARENESS, KNOWLEDGE AND INTENTION TO TAKE
HPV VACCINATION AND CERVICAL CANCER SCREENING IN NIGERIA ……..39

CHAPTER 4: ADDRESSING STIGMA AND IMPROVING HPV AND CERVICAL

CANCER KNOWLEDGE AMONG MEN AND WOMEN IN NIGERIA: ASSESSMENT
OF A COMMUNITY-BASED EDUCATIONAL INTERVENTION ……………...…...71

CHAPTER 5: CONCLUSION AND RECOMMENDATION………….………………94

REFERENCES…………………………………………………………………………101

APPENDIX A: INFORMED CONSENT FORM…………………………………..….124

APPENDIX B: QUESTIONNAIRE FOR MEN…………………………………….....126

APPENDIX C: QUESTIONNAIRE FOR WOMEN…………………………………..130

viii
 LIST OF TABLES

Table 3.1: Summary of Participant Demographics……………………………………….49

Table 3.2. Participant Knowledge of HPV and HPV Vaccine Pre- Intervention and Post-
Intervention………………………………………………………………………………51

Table 3.3 Participant Knowledge of Cervical Cancer and Cervical Cancer Screening Pre-
intervention (Pre) and Post intervention (Post)………………………………………..….53

Table 3.4: Participants Level of Knowledge of HPV, HPV Vaccine, Cervical Cancer and
Cervical Cancer screening Pre and Post intervention……………………………………54

Table 3.5: Participant HPV Vaccine and Cervical Cancer Screening Rate………..…….55

Table 3.6. Participant Intention to Encourage and or Take HPV Vaccine.…………..….56

Table 3.7. Participant Intention to Encourage and or Take Cervical Cancer

Screening…………………………………………………………………………………57

Table 3.8: Participant Regression Analysis of Factors Associated with Higher Knowledge
of HPV and HPV Vaccine………………..……………………………………………...59

Table 3.9: Participant Regression Analysis of Factors associated with Lower Knowledge
of Cervical Cancer and Cervical Cancer Screening……………………………….…….60

Table 4.1: Summary of Participants’ Characteristics……………………………………79

Table 4.2: Participants’ Knowledge of HPV and HPV Vaccine……………………..….81

Table 4.3. Participants’ Knowledge of Cervical Cancer and Cervical Cancer

Screening………………………………………………………………………………...82

Table 4.4: Participants Knowledge of HPV, HPV Vaccine, Cervical Cancer and Cervical
Cancer Screening Pre- and Post……………………………………………………….....83

Table 4.5. Participant Perception of Stigma Associated with HPV Infection and Cervical
Cancer…………………………………………………………………………...……….85

Table 4.6: Participant Regression Analysis of Factors Associated with Higher Knowledge
of HPV and HPV Vaccination……………….…………………………………………...86

ix
Table 4.6: Participant Regression Analysis of Factors Associated with Higher Knowledge
of Cervical Cancer and Screening…………………………….…………………..……...87

x
 LIST OF FIGURES

Figure 1.1: Proposed Modified Theory of Gender and Power…………………………...11

Figure 1.2: Modified Precaution Adoption Process Model……………………………...12

xi
 LIST OF ABBREVIATIONS

CDC ................................................................. Centers for Disease Control and Prevention

CHW ........................................................................................ Community Health Workers

HPV...................................................................................................Human Papillomavirus

HSA....................................................................................... Health Surveillance Assistants

ICPD…………………………...International Conference on Population and Development

IgG .......................................................................................................... Immunoglobulin G

NPC .................................................................................. National Population Commission

PAPM........................................................................... Precaution Adoption Process Model

SSA ........................................................................................................ Sub-Saharan Africa

STI........................................................................................ Sexually Transmitted Infection

TGP ......................................................................................... Theory of Gender and Power

UNFPA………………………………………………......United Nations Population Fund

UNICEF…………………………………………………...United Nations Children's Fund

VIA ............................................................................... Visual Inspection with Acetic Acid

WHO .......................................................................................... World Health Organization

xii
 CHAPTER 1

INTRODUCTION

Background

Human Papillomavirus (HPV) refers to small, double-stranded DNA viruses with

more than 150 identified types. Each virus is classified according to their oncogenic

potential into low-risk and high-risk HPV types (Centers for Disease Control and

Prevention, [CDC] 2017). HPV is the most common sexually transmitted infection,

commonly spread through intimate skin-to-skin contact by having vaginal, anal, or oral

sex. HPV transmission from hands to genitals or genitals to hands have also reported for

both sexes and heterosexual couples (Liu, 2016). HPV has been found to be resistant to

heat and desiccation, therefore non-sexual transmission of the virus is possible (Ault,

2006). HPV is so common that most sexually active men and women will be infected with

at least one type of HPV at some point in their lives. It is difficult to detect when an

individual first became infected with HPV as symptoms can develop years after infection

(CDC, 2017).

The vast majority of HPV infection is asymptomatic and will clear without medical

intervention; but those who contract persistent high-risk HPV types may develop cancer.

HPV is estimated to cause about 5% of human cancers (de Martel et al., 2012; Bosch et al,

2013), including anogenital cancers (cervical, vaginal, vulvar, penile, and anal) and

oropharyngeal cancer (CDC, 2017). The prevalence of HPV among general population is

unknown in Nigeria but studies had reported 42.9% of women in a state in the northern

1
region (Aminu et al., 2014) and 26.3% of the general population in Southern Nigeria had

HPV-IgG antibodies (Aminu et al., 2014; Bruni et al., 2014; Okolo et al., 2010).

Furthermore, the age-specific prevalence revealed that 52% of Nigerian women ≤ 30 years

had an HPV infection compared to 23% of women who were older than 45 years (Akarolo-

Anthony et al., 2014).

HPV infection is responsible for more than 90% of cervical cancers (CDC, 2017),

and Nigeria has one of the most extensive epidemics of cervical cancer in sub-Saharan

Africa (Ferlay et al., 2014; Oguntayo et al., 2011). Cervical cancer is the second most

common female cancer in many parts of Nigeria (Oguntayo et al., 2011), with a high

incidence and mortality rates. On average, one Nigerian woman dies of cervical cancer

every hour (Federal Ministry of Health [FMoH], 2014). The age-standardized incidence

rate of cervical cancer is 34.5 per 100,000 (Ferlay et al., 2014). There is an upsurge in

invasive cases, as retrospective studies in three tertiary hospitals in three different regions

(Jos, Zaria, and Nnewi) of the country, found that more than 70% of the patients presented

with advanced stage cervical cancer (Ikechebelu, Onyiaorah, Ugboaja, Anyiam, & Eleje,

2010; Musa et al., 2016; Oguntayo et al., 2011).

Even with the reported high burden of cervical cancer in Nigeria, accurate

morbidity and mortality rates are unknown, due to gross underreporting, misdiagnosis,

suboptimal record keeping and improper data from poorly funded cancer registries. It is

predicted that there will be 19,440 new cervical cancer cases and 10,991 cervical cancer

deaths by 2025 in Nigeria (Ferlay et al., 2014). The risk of HPV infection and cervical

cancer can be significantly reduced by HPV vaccination, Pap smear, Visual Inspection with

Acetic Acid (VIA) and HPV test.

2
Prevention

HPV Vaccine. HPV vaccines have fostered the hope of eradication of HPV

infection and cervical cancer. The two types of HPV vaccines, Gardasil™and Cervarix™

provide protection against HPV infection. Gardasil is a quadrivalent vaccine that protects

against HPV types 6, 11, 16, and 18, while Gardasil-9 is a nine-valent HPV vaccine that

protects against HPV types 6, 11, 16, 18, 31, 45, 52, and 58 (CDC, 2016). Cervarix is a

bivalent vaccine that gives protection against HPV types 16 and 18. The World Health

Organization (WHO) recommends HPV vaccines for boys and girls aged 9 through 26

(WHO, 2014), while Center for Disease Control and Prevention recommends HPV

vaccination for preteen girls and boys at age 11 or 12 years and teens and young adults who

did not start or finish the vaccine series until they are 27 years old for women and 22 years

old for men. Two doses of HPV vaccine at least six months apart was recommended for

11- to 12-year-olds, and a three doses series is recommended for teens and young adults

who start the vaccine later than ages 15 (CDC, 2016).

The 2015 HPV vaccination guidelines by the American College of Obstetricians

and Gynecologist Committee do not recommend testing for HPV DNA prior to vaccination

in any population group; recommend vaccination among individuals who test positive to

HPV DNA and do not recommend routine pregnancy testing before HPV vaccination.

However, the guidelines warn that HPV vaccine should not be taken in pregnancy. HPV

vaccination is recommended for women regardless of sexual activity status (Munoz, et al.

2010; Paavonen, et al. 2010); for individuals who did not receive the vaccine at an early

age, and for men and women with compromised immune systems (including people living

3
with HIV/AIDS) through age 26, if they did not get fully vaccinated when they were

younger (CDC, 2014).

Cervical Cancer Screening. HPV vaccination is projected to reduce substantial

prevalence of specific HPV 16/18 infections, cervical abnormalities and invasive cervical

cancer, if population coverage is high above 70% (WHO, 2009). Once in a lifetime

screening, performed by women in their 30s or 40s could reduce the risk of cervical cancer

by 25-30% (WHO, 2014). The implementation of Pap smear, Visual Inspection with Acetic

Acid (VIA) and HPV screening is essential for detecting the HPV virus and early cell

changes on the cervix. Pap smear and VIA facilitates early detection and successful

treatment of precancerous cervical lesions. Pap smear is recommended for all women

between the ages of 21 and 65 years old (CDC, 2016). Women who are 30 years old or

older are encouraged to have an HPV test along with the Pap smear (CDC, 2016). The HPV

test is a “qualitative multiplex assay that simultaneously provides specific genotyping

information for HPV types 16 and 18, and a pooled result of 12 high risk strains of HPV

DNA’’ (Roche Molecular Inc., 2014, p.10). HPV tests eliminates the need for an initial

pelvic exam by providing women an opportunity to collect samples of their own vaginal

cells for testing (Arbyn et al, 2014). With normal pap test results, a woman is expected to

wait for three years before repeating another Pap test (CDC, 2017; Ronco et al., 2014).

With normal HPV test and Pap test results, a woman can wait as long as 5 years before

getting another screening test (Ronco et al., 2014), as her chances of getting cervical cancer

in the next few years is very low (CDC, 2017).

The World Health Organization (WHO), together with CDC and other health

organizations included visual inspection with acetic acid (VIA) and treatment with

4
cryotherapy in the cervical cancer screening guidelines as screening methods for cervical

cancer in low-resource settings (WHO, 2013; CDC, 2015). VIA involves staining the

cervix with a 5% acetic acid (vinegar) solution, and an abnormal cervical tissue turns white

after 30 to 60 seconds. VIA has helped increase the detection of precancerous cells by

increasing screening coverage in some developing countries (WHO, 2012; Quentin et al.,

2011; Nessa et al., 2010; Zhang et al., 2010; Mwanahamuntu, et al., 2011; Mwanahamuntu,

et al., 2013). In Nigeria, the uptake of cervical cancer screening is extremely low, as fewer

than 10% of Nigerian women have ever had a cervical cancer screening (Idowu,

Olowookere, Fagbemi, & Ogunlaja, 2016; Wright, Aiyedehin, Akinyinka, & Ilozumba,

2014). Poor uptake of cervical cancer screening was documented even among health

providers in Lagos Nigeria, where 60% of the nurses reported never having been screened

for cervical cancer (Awodele et al., 2011).

Barriers

The low uptake of HPV vaccine and cervical cancer screening in Nigeria is

exacerbated by multiple personal, social, political and institutional factors. Reported

barriers include: lack of awareness of the vaccine; poor knowledge of disease and screening

techniques; erroneous perceptions, cultural beliefs and practices; fear of pain from the

procedure; fear of the outcome of the test; lack of decision making ability and spousal

support; stigma and modesty, the cost of screening, barrier to access, associated costs,

deficiencies within the health care system and health facilities (Ezenwa, Balogun, &

Okafor, 2013; Lim & Ojo, 2017; Modibbo, et al., 2016; Ndikom, Ofi & Omokhodion,

2014). Even among urban and educated Nigerian women, the level of awareness and

5
knowledge of cervical cancer were found to be low (Hyacinth, Adekeye, Ibeh & Osoba,

2012).

With prevention and early detection, HPV infection and cervical cancer are largely

avoidable diseases. The incidence of HPV infection and cervical cancer are very high in

Nigeria due to poor uptake of cervical cancer screening measures and HPV vaccine.

Cervical cancer has a profound societal impact as it mainly affects women between the

ages of 30 to 50, who are often raising or supporting families (Goumbri, Domagni, Sanou,

Konsegre, & Soudre, 2009). Although cervical cancer affects only women, HPV affects

both men and women equally. A woman’s risk of contracting HPV infection and

subsequently developing cervical cancer does not depend on her sexual behavior alone, but

also on her male partner(s)’ sexual activities, as men are both vectors and carriers of HPV.

Lack of spousal support, stigma and modesty are social barriers that are beyond the control

of the woman and require the involvement of men.

The impact of sociocultural factors, including lack of spousal support, is widely

recognized as hindering the uptake of cervical cancer preventive measures (Ezeonwu,

2014; Modibbo et al., 2016). This is not surprising, given that Nigeria is a male-dominated

society where men are in charge of economies, are the sole family decision-makers, and

women are subservient to male family members (Ifemeje & Ogugua, 2012; Lim & Ojo,

2017). Only 15% of Nigerian women have a personal bank account (Council, 2012); only

one-third of currently married women participate in household decisions; only 40% of

married women participate in decisions about their own health and 50% do not participate

in any decisions made in the household (National Population Commission and ICF

International, 2014).

6
 Since the mid-1990s, the importance of involving men in reproductive health

programs has gained increasing recognition, along with attention to the sociocultural

factors affecting women’s reproductive health. The World Health Organization (2006)

recommended involving men in the prevention of cervical cancer in middle and low-

income countries. Studies conducted in developing countries have suggested that lack of

male involvement may be an overlooked obstacle to cervical cancer screening (Kim et al.,

2012; Lim & Ojo, 2017; Lyimo & Beran, 2012). Men play critical roles in women's abilities

to seek health care, yet, more often than not, they are uninformed about both their own and

women's reproductive health needs. Despite the role men play in their partners’

reproductive health experiences, HPV and cervical cancer programs in Nigeria have

focused only on women in reducing the incidence of HPV and cervical cancer; and little

attention has been devoted to the social factors that expose women to HPV infection, and/or

hinder them from taking the preventive measures.

As will be discussed in more detail in Chapter 3, prior research has shown that

increasing awareness and knowledge of HPV, HPV vaccination, and cervical cancer, and

cervical cancer screening has been effective in increasing both behavioral intention and

behavior (Wright, Kuyinu, & Faduyile, 2010; Ndikom, Ofi, Omokhodion, & Adedokun,

2017). The aim of this research was to implement an educational intervention, delivered

using two strategies: one that could be efficiently delivered to groups in natural settings

such as churches, and one that could be delivered to individuals who may not be accessible

in group settings in order to reach as many people in the target population as possible.

Members of the target population who are accessible and amenable to a community-based

group intervention versus a community-based individual intervention likely have

7
meaningfully different sociodemographic characteristics and, possibly, differing baseline

knowledge and beliefs about HPV, cervical cancer, and the associated risk reduction

methods. Thus, the overall purpose of this study is to establish the feasibility of delivering

group and individual interventions to the target population, and to test the independent

outcomes of each intervention rather than on comparing the two interventions.

Study Aims and Research Questions

The primary aim of this research was to determine the effectiveness of a community-

based educational intervention delivered in groups or to individual men and women living

in an urban area of southeastern Nigeria. The goal was to increase knowledge of HPV

infection and cervical cancer, and intention to take and or encourage HPV vaccine and

screening. Specific research questions were:

For each community-based educational intervention strategy:

What is the level of knowledge of HPV and cervical cancer at post-test versus pre-

test?

What is the intention to take and or encourage HPV vaccine and cervical cancer

screening at post-test versus pre-test?

What is the stigma associated with HPV and cervical cancer at post-test versus pre-

test?

What variation in knowledge of HPV and cervical cancer were observed among

participants based on age, marital status and educational level at post-test versus

pre-test?

8
 Theoretical Framework: The Theory of Gender and Power (TGP) was selected to

guide the exploration of male participation in cervical cancer prevention and the need for

an educational intervention, considering the low awareness, poor knowledge and low

uptake of HPV vaccine and cervical cancer screening. In addition to TGP, the Precaution

Adoption Process Model guided the study.

TGP is a social structural theory that explore the depths of sexual inequity, gender

and power imbalance (Connell, 1987). Connell identified three major structures that

characterize the gendered relationships between men and women: the sexual division of

labor, the sexual division of power, and the structure of cathexis. The three major structures

are less evident in the institutional level but remain largely intact at the societal level over

a long period, even as society slowly changes.

The sexual division of labor refers to occupational differentiation by gender

(Connell, 1987). Nigerian women are generally assigned to lower paying jobs, positions

and salaries or relegated to non-income generating labor such as housework, taking care of

farmland, childrearing, and caring for the dependent member of the family. This type of

work does not have assigned economic wages, so women often earn nothing from doing

them. This makes them financially dependent, relying on men for all their needs; thus,

constraining women and limiting their economic potential and career paths. These gender-

determined roles and discriminatory practices relegate Nigerian women to domestic work,

unequal pay for comparable work, prescribed behaviors and expectations, and power

imbalance within relationships (Ifemeje & Ogugua, 2012).

The sexual division of power deals with the inequalities in power between men and

women. This structure at the household level is maintained by social practice, such as

9
through the abuse of authority, control in relationships and marginalization of women

(Wingood & DiClemente, 2000). Nigerian culture reinforces women to see themselves as

the lesser gender, be more submissive and subordinate to the male gender (Nnadi, 2013).

The recent National Population Commission report revealed that only one-third of

currently married Nigerian women participate in household decisions, and nearly four in

ten married women participate in decisions about their own health care. Half of the married

women do not participate in any decisions made in their home (NPC & ICF International,

2014). Gender power inequality, especially in the form of relationship power imbalances,

plays a role in sexually transmitted infection (Smith, 2007).

The structure of cathexis, also referred to as the structure of social norms and

affective attachment, addresses the affective nature of relationships between men and

women. It dictates appropriate gender role, the sexual expectations and prescribed

behaviors of each gender at the societal level. This structure describes the constrained

expectations the society has for women regarding their sexuality, and consequently, shapes

their perceptions and limits their experiences of reality.

The prescribed cultural gender roles limit communication and shared decision

making among couples especially on sexually related matters (Dunkle et al., 2007). Sexual

related issues are deemed sensitive and are rarely discussed in most Nigerian communities,

which often affect communications in marriage, thus hindering women’s expression of self,

request of what they want and discussion of their reproductive health with their spouses.

10
 Male Involvement

Sexual division of power

Physical exposures
Partner disapproval of service
use
Male preference
Physical and sexual abuse
High risk steady partner
Older partner

Women
vulnerability to
HPV infection and
cervical cancer Structure of Cathexis
Sexual division of labour
Social exposure
Socio-economic exposure
Conservative cultural and
No/low finance gender norms
Un/underemployment Low self-efficacy to take
Low educational attainment action
Early marriage Cultural/religious norm of
Few political/policy-making modesty
positions Limited expectations and
movements

Increased uptake of HPV vaccine and

Cervical cancer screenings

Figure 1.1: Proposed Modified Theory of Gender and Power

Methodological Model. The Precaution Adoption Process Model (PAPM)

explains how a person comes to decisions to take action and how he or she translates that

decision into action (Weinstein & Sandman, 1992). The adoption of a new behavior or

precaution or cessation of an unhealthy behavior requires deliberate steps unlikely to occur

outside of conscious awareness. The model identifies seven stages along the path from lack

of awareness to maintenance of action over time. Given that this research only focused on

11
knowledge and intention to take HPV vaccine and Pap smear, only the first five stages of

the PAPM apply. Figure 1.2 illustrates the application of the five stages of the Precaution

Adoption Process Model to this research, with the aim of increasing the knowledge of HPV

and cervical cancer, and intention to take HPV vaccine and cervical cancer screening.

Stage 1 Stage 2 Stage 3 Stage 5

Information More attention on Contemplating Intention to take
about HPV the severity of the avoiding the or encourage
infection, diseases and the risk factors and partner to take
Cervical cancer, benefit of the uptake of HPV HPV vaccine
and their preventive vaccine and and cervical
preventive measures cervical cancer cancer
measures screenings screenings

Stage 4
Intention to not
take or
encourage
partner to take
HPV vaccine
and cervical
cancer
screenings

Figure 1.2: Modified Precaution Adoption Process Model

Stage 1 represents the initial point in time when people become aware of HPV

infection and cervical cancer. Awareness is the first step to developing an attitude or belief

about an issue. Individuals who have never heard of HPV infection and cervical cancer,

cannot have formed opinions or beliefs about the disease or preventive measures. Creating

awareness on HPV and cervical cancer is vital in building knowledge. Stage 2 represents

the point at which individuals first receive information or learn about the HPV infection

and cervical cancer, although they are not yet engaged by this information. Being aware of

12
a disease or its preventive measures increases the possibility of developing an opinion

about them. However, people will think about an issue or develop an opinion depending

on the level of awareness or the quality of information known. In terms of this research,

the educational interventions are designed to both create awareness and provide

participants with information on HPV, cervical cancer, HPV vaccine and cervical cancer

screening. The aim is to encourage participants to think about both the disease and the

available preventive measures.

Providing adequate information stimulates thoughts about the issue, and people

begin to consider the issue and have an opinion about it, represented in Stage 3. It is quite

common for people to be aware of an issue without being personally engaged with the

issue. When they become engaged, they begin to think of assuming a position.

Furthermore, people who have a definite position on an issue decide either to take or not

to take action. The outcomes of Stage 3 (decision making time) will vary depending on

individual differences. Some people may suspend judgment and remain in stage 3 for some

time. Others may decide not to take action (Stage 4). Deciding not to take action means

halting the precaution adoption process at least for the time being. Deciding to take action

by adopting the precaution is represented in Stage 5. Whichever position an individual

assumes results in overconfidence in one’s beliefs; searches for evidence to favor one’s

beliefs, interpretations of data to favor beliefs; and insufficient adjustment of beliefs in

light of new evidence (Klayman, 1995). One factor that influences people’s decision

regarding HPV vaccination is perceived susceptibility (Connor & Norman, 1995). The aim

of the educational interventions was to enhance participants’ recognition of their or their

13
family members’ susceptibility to HPV infection and cervical cancer risk. The following

chapter contains the research plan.

Overview of Manuscripts and Target Journals

This dissertation is organized in the manuscript format. The aim of this research

was to assess if a community-based educational intervention delivered to men and women

living in an urban area of Nigeria would increase the knowledge of HPV infection and

cervical cancer, increase intention to take HPV vaccine and screening, and reduce stigma

about HPV infection and cervical cancer. The community-based health education

intervention included participants who received a face-to-face presentation on HPV

infection, cervical cancer, HPV vaccination and cervical cancer screening (Presentation

Group) and individual participants who read a pamphlet containing similar information

(Pamphlet Group). A total of 281 men and women between the age of 18 and 65 years who

could- read and write in English and resided in Anambra state participated in the study.

The survey instrument, a self-administered survey, was given to the participants before and

after the intervention.

Data analysis consisting of descriptive statistics (frequency and percentage)

inferential statistics (T-test, Chi-square and logistic regression) were done using Statistical

Analysis System (SAS) software. This study is significant in many ways and has

importance to diverse audiences. The findings from this study may assist governments and

Non-governmental organizations in planning interventions to increase HPV vaccination

and cervical cancer screening in Nigeria. In addition, program planners and researchers

may build on the findings or use the findings to guide future research on HPV and cervical

cancer.

14
 The first manuscript is a scoping review of male participation in reproductive health

interventions in sub-Sahara Africa. The manuscript emphasizes men’s shared

responsibility and active involvement in sexual and reproductive behavior as an important

step in improving reproductive and maternal health. The review synthesis examined and

describes the outcome of men’s participation in various reproductive health programs such

as family planning, birth preparedness, dual protection from HIV/sexually transmitted

infections (STI), and maternal health service utilization carried out between 2007 and 2018

in Sub-Sahara Africa. This manuscript has been submitted to the International Perspective

on Sexual and Reproductive Health Journal.

The next two manuscripts describe the effectiveness of the community-based health

education intervention in improving knowledge of HPV and cervical cancer, increasing

intention to take HPV vaccine and cervical screening and reducing HPV and cervical

cancer stigma among men and women in Nigeria. The first manuscript details the changes

in awareness, knowledge and intention to take to HPV vaccination and cervical cancer

screening before and after the educational intervention. (Chapter 3). The manuscript will

be submitted to the International Journal of Public Health. The second manuscript describes

an evaluation of educational intervention to reduce stigma associated HPV and Cervical

cancer in Nigeria. The target journal for this manuscript is the Global Public Health

Journal.

15
 CHAPTER 2
MALE PARTICIPATION IN REPRODUCTIVE HEALTH INTERVENTIONS IN

SUB-SAHARAN AFRICA: A SCOPING REVIEW

16
Background

Over the past two decades, there has been only minimal improvement in women’s

reproductive health indicators in the African region (WHO, 2014). Reproductive and

sexual health problems represent one-third of the total global burden of disease for women

between the ages of 15 and 44 (WHO, 2013). Maternal mortality rates in the region are

among the highest in the world, with nearly half of the estimated 830 daily maternal deaths

occurring in sub-Saharan (Alkema et al., 2016). Hypertension during pregnancy (e.g., pre-

eclampsia and eclampsia), complications from delivery, unsafe/unattended abortion, and

postpartum hemorrhage and infections account for nearly 73% of all maternal deaths

worldwide (Say et al., 2014). Over the past 20 years, the maternal mortality rate in Africa

has declined only 2.7%, yet the maternal mortality rate needs to continue to decline at least

5.5% per year in order to reach the Millennium Development Goal 5 of universal access to

reproductive health with a 75% reduction in the maternal mortality rate and in the African

region (WHO, United Nations Department of Public Information [UNICEF], United

Nations Children's Fund [UNFPA], The World Bank, 2012). Given that between 1990 and

2010 the total rate of decline was only 2.7%, it is clear that persistent challenges to

improved maternal health are not being adequately addressed.

Persistent gender, social and ethnic disparities continue to inhibit progress in

women’s health across the globe (International Conference on Population and

Development [ICPD], 2014). In Sub-Sahara Africa, gendered cultural beliefs and practices,

and limited access, affordability, and utilization of health facilities contribute to women’s

health disparities. Culturally, men are the decision makers and gatekeepers in most African

families and therefore hold power and influence over decisions regarding women’s access

17
to health services, contraception and prevention of sexually transmitted infections (STI).

Furthermore, men often control the allocation of money, transportation, time and

permission women need to access health services.

The importance of involving men in reproductive health programs has gained

increasing recognition since the mid-1990s, and there is increasing recognition that men’s

participation in reproductive and sexual health is an important step in supporting women’s

health and improving family health. Formally recognized at the 1994 International

Conference on Population and Development, at the 1995 Women's International

Conference in Beijing, three avenues for men’s active inclusion and shared responsibility

in women’s health were identified: (1) promoting men’s use of contraceptives through

increased education and distribution; (2) involving men in roles supportive of women’s

sexual and reproductive decisions; and (3) encouraging men to indulge in responsible

sexual and reproductive practices to prevent and control STIs (United Nations Department

of Public Information, 1995; UNFPA, 2004).

Researchers have explored the importance of men’s involvement in women’s

decision-making and use of reproductive health services in Sub-Sahara Africa in various

studies using a wide range of research designs and methods. An assessment of women’s

sex preference, decision making and fertility control in the Ekpoma community in south

southern Nigeria showed that more than half of the women believed it is the man’s right to

make the final decisions in the home including reproductive decisions (Agatha, Sims, &

Godfrey, 2007). Similarly, an examination of the motivations and preferences of rural

Nigerian women undergoing cervical cancer screening indicated the most frequently

reported motivating factors of women’s participation in cervical cancer screening were the

18
support and opinion of her husband and the community leaders (Chigbu, Onyebuchi, Ajah,

& Onwudiwe, 2013). Not surprising, in studies conducted in both Burkina Faso Sawadogo,

Gitta, Rutebemberwa, Sawadogo, & Meda, 2014) and Nigeria (Ezeonwu, 2014; Modibbo,

2016), lack of spousal support was identified as one of the reasons for women not being

screened for cervical cancer.

Recognizing the sociocultural factors exposing women to a higher risk of

contracting sexual transmitted infections, the Joint United Nations Programme on

HIV/AIDS (UNAIDS, 2010) called for development and implementation of innovative

strategies to further educate men about women’s health. To further strengthen and promote

the recommendation of male involvement in reproductive health interventions, it is

imperative to examine the impact of male involvement in reproductive health interventions

(family planning, sexual risk behaviors, antenatal care, birth preparedness, maternal

health). Reproductive health program planners and researchers have employed various

interventions involving men in an effort to improve reproductive health and increase the

utilization of reproductive health services. Examples include invitation letters, home visits,

community events and use of community health workers. The previously published

reviews on male participation in women’s health issues in Sub-Sahara Africa focus on

prevention of mother-to-child transmission of HIV, HIV counselling and testing, HIV

reduction barriers and facilitators as opposed to interventions to improve reproductive

health (Auvinen, Kylma, & Suominen, 2013; Burton, Darbes, & Operario, 2010; Hensen,

Taoka, Lewis, Weiss, & Hargreaves, 2014; Morfaw, et al., 2013). The specific aim of this

scoping review was to examine evidence published between 2007 and 2018 related to

evaluation of reproductive health interventions that involved men in efforts to improve

19
reproductive and maternal health in Sub-Sahara Africa from 2007 to 2018. This review is

of interest to health care providers, researchers and public health planners concerned with

reproductive health issues, particularly among women in Sub-Saharan Africa, but also in

other regions of the globe.

Methods

We conducted multiple searches through Google Scholar, PubMed, Science Direct,

Medline, Global Health, PsycInfo and Cumulative Index to Nursing and Allied Health

Literature. Search terms were related to male involvement (i.e., male, men, spouse, couple,

involvement, participation, engagement, program, trials, spouse; couple) in reproductive

health issues (i.e., family planning, sexual risk behaviors, antenatal care, birth

preparedness, maternal health, reproductive health, maternal health, sexual health; family

planning; antenatal care, condom use, birth preparedness) in Sub-Sahara Africa (i.e.,

Nigeria, Malawi, Ethiopia, Tanzania). Once retrieved, articles were further screened using

the following inclusion criteria: (1) articles published in English between January 2007 and

March 2018; (2) reports of reproductive health interventions involving men in Sub-Saharan

Africa; and (4) reports of research that employed an experimental or quasi-experimental

study design. Subsequent to the identification of relevant sources, the reference list of each

identified article was reviewed to identify additional eligible studies (three articles were

included). Excluded were reports of programs that only addressed prevention of mother-

to-child transmission of HIV and HIV counselling and testing.

The initial electronic bibliographic search yielded titles of 2,847 articles, including

1,313 duplicates which were subsequently excluded. An examination of the titles of the

remaining 1,534 articles resulted in further exclusion of 1,275, yielding a sample of 259

20
research reports that met the inclusion criteria for full-text review. Of these, 18 articles met

the criteria and were submitted to independent review by a second independent examiner,

who independently examined all 18 full texts and confirmed all manuscripts met the

inclusion criteria. Subsequently, the following information from each study was entered

into a Microsoft Excel database: title, authors, publication date, intervention-publication

interval, sample characteristics, location, study design, type of reproductive and/or

maternal health program, data collection method(s), comparison group, outcome measures,

intervention characteristics (i.e., number and types of intervention strategies, outcome

measures), and intervention strategies (i.e., individual or couple-based approaches). One

person extracted, and both reviewed; and reviewers discussed any disagreements in the

data extracted.

Results

The final sample consisted of 18 interventions articles were published between

2007 and 2018, each of which included an evaluation of men’s involvement in a

reproductive health intervention in Sub-Saharan Africa. The articles included research

conducted in Nigeria (n=6), Malawi (n=5), Tanzania (n=3), Uganda (n=2), Ethiopia (n=1),

Senegal (n=1), Kenya (n=1) and Mozambique (n=1). Couples, men living with female

partners, and men only were the most common target group (17); one study involved only

women with information focused on men and encouraged women to deliver the

information. The majority of the participants were 18 years of age and above, although six

studies included participants as young as 14 and 15 years. The reproductive health outcome

measures were family planning (n=9), maternal health/service utilization (n=8), HIV

counselling and testing (n=4), birth preparedness (n=1), dual protection from HIV/STI

21
(n=1) and uptake and adherence of antiretroviral therapy (n=1). The research designs

included surveys, interviews and focus groups. Five studies included a theory-based

intervention to assess impact of male involvement in reproductive health (Adeleye &

Okonkwo, 2016; Adeleye, Aldoory, & Parakoyi, 2011; Exner et al., 2009; and Hartmann

et al., 2012; Shattuck, et al., 2011). Overall, the study designs reported in the articles were

12 quantitative, 1 qualitative, and 5 mixed methods studies.

Intervention Theoretical Framework and Design

The most common theoretical frameworks were Gender Theory and the

Information-Motivation-Behavioral Skills Model. Adeleye & Okonkwo, (2016) and

Adeleye, Aldoory, & Parakoyi, (2011) employed the Gender Theory to explore maternal

health services utilization. Gender Theory posits that gender constitutes the social,

economic, and political contexts that guide particular beliefs, norms, and behaviors. In their

research conducted in Malawi, Shattuck, et al., (2011) and Hartmann et al., (2012)

employed the Information-Motivation-Behavioral skills model which postulates that

health-related information, motivation, and behavioral skills are important determinants of

whether a family planning behavior is performed. Exner et al., (2009) used the Stages of

Change Model to guide the intervention to promote dual protection against HIV/STI.

In terms of research design, there were three randomized controlled trials (RCTs),

eleven studies that employed a pretest/posttest design and four studies that were posttest-

only. Furthermore, eight studies had a comparison group and fifteen studies used at least

three intervention strategies. In this review, 10 studies were couple-based interventions,

seven studies targeted only men and one study targeted only women. The couple-based

interventions were focused on family planning, HIV counselling and testing and maternal

22
health services utilization. The studies that targeted only men explored HIV/STI dual

protection, maternal health services utilization, birth preparedness and family planning.

Interestingly, one study had only women as the study participants, and the purpose was to

assess the women’s perspectives about the impact a maternal health mass media campaign

had on their husbands. Almost all the studies assessed the impact of male involvement in

marriage relationships and/or co-habiting relationships. Nine studies were conducted in

urban settings, eight studies were conducted in rural settings and one study involved

participants residing in both urban and rural settings.

Intervention Content and Outcomes

Uptake of family planning services was the primary outcome measure in the

majority of the studies (n=9), followed by maternal health service utilization (n=6).

Collectively, these studies indicated that inclusion of men in reproductive health

interventions is an essential component of effective reproductive health interventions in

Sub-Saharan African.

Men’s Willingness to Participate

Studies conducted in Nigeria, Ethiopia, and Uganda evaluated men’s willingness

to participate and complete the reproductive health programs. The reports indicated high

participation and retention among their participants. The use of local culture and gender

roles to improve men’s involvement in maternal health, Adeleye, Aldoory, and Parakoyi,

(2011) reported that about 90% of the participants attended nine group health talks which

averaged 2 hours in duration and were conducted over in 4-week period in Nigeria. In

similar study in Nigeria, more than 90% of the respondents had attended a two-hour

educational session on maternal death (Adeleye, Aldoory, & Parakoyi, 2011). Exner and

23
colleagues (2009) observed that the majority (91 %) of the men who participated in a

program to increase dual protection against HIV/STI attended two five-hour sessions

scheduled one week apart, and 75% attended both monthly two-hour ‘check-in’ sessions

post-intervention (Exner et al., 2009).

Furthermore, among couples who participated in a family planning intervention

aimed at encouraging spousal communication, 92% of the couples responded to face-to-

face discussions (Tilahun, Coene, Temmerman, & Degomme, 2015). Similarly,

Ghanotakis and colleagues (2016) reported 65% of male participants attended all 10

sessions focused on transforming gender norms and encouraging uptake of family planning

and HIV services. Interestingly, nearly all participants reported complete trust in the

credibility of the information shared and high satisfaction with the workshop. These

findings challenge the conventional assumptions and stereotypical perceptions that most

African men are not interested in participating in programs involving women’s health and

healthcare services (Chipeta, Chimwaza, & Kalilani-Phiri, 2010; Olawoye et al., 2005).

These findings clearly suggest African men are willing to participate in reproductive health

programs, either individually or with their partner/spouse and provide further support for

the notion that providers, researchers and program planners should be attentive and actively

respond to opportunities to include men in reproductive health programs and services.

Couple-Oriented Interventions

There were ten examples of reproductive health interventions designed for married

or co-habituating partners. The focus of these interventions was either family planning

uptake (Hartmann, Gilles, Shattuck, Kerner, & Guest, 2012; Shattuck, et al., 2011; Tilahun,

Coene, Temmerman, & Degomme, 2015; Becker, et al., 2014; Lemani, et al., 2017) or

24
maternal health (i.e., obstetric care, antenatal care, skilled birth attendance) alone or with

HIV counselling and testing and or gender norm transformation (Jefferys, et al., 2015;

Byamugisha, et al., 2011; Bright, et al., 2015; August, Pembe, Mpembeni, Axemo, & Darj,

2016; Mushi, Mpembeni, & Jahn, 2010). Intervention contents namely, education,

counseling, behavioral skills, home visits, follow-up visits and community events were all

efficacious strategies that resulted in positive outcomes.

Further, community-engaged and collaborative approaches such as community-

based participatory research (CBPR) were defining characteristics of these programs to

generate meaningful outcomes. Trained community health workers (CHWs) were used in

six studies, to provide the community interventions (Hartmann, Gilles, Shattuck, Kerner,

& Guest, 2012; Becker, et al., 2014; Lemani, et al., 2017; August, Pembe, Mpembeni,

Axemo, & Darj, 2016; Mushi, Mpembeni, & Jahn, 2010; Audet, et al., 2016). In these

instances, CHWs were members of the local community, without formal professional

health training. They were referred to by a variety of terms, including promoters,

traditional birth attendants, male champions, community health counselors, community

agents, lay providers, and peer support specialists. For example, August and colleagues

employed and trained trusted men and women who had completed primary school and

could read and write in the villages to identify pregnant women in the community and make

at least four visits to the family throughout the pregnancy (August et al, 2016). Similarly,

health surveillance assistants, stratified by sex and catchment area, visited women from

their catchment areas in their homes and counseled them on family planning alone and with

the male partner. The Health Surveillance Assistants (HSA) would then initiate the family

25
planning method of the woman’s choice if the woman asked for a short-term method or

refer her to the nearest facility for long-term family planning methods (Lemani et al, 2017)

Utilization of community-based approaches to health promotion and prevention

may reduce the challenges of standard research approaches, strengthen the rigor and utility

of science for community applicability, enhance evidence-based translation to local

communities, and demonstrate both individual and community benefit (Horowitz,

Robinson, & Seifer, 2009). For example, Audet and colleagues (2016) conducted a

community participatory action program in Mozambique that integrated and deployed

CHWs to the community to engage men in prenatal care services and increase HIV testing

and treatment uptake. The CHWs established a male-friendly clinical environment and

provided couples counseling sessions. The CHW intervention increased male

accompaniment at antenatal care appointments, HIV testing among pregnant woman, male

partner presence at antenatal visits, maternal attendance at a minimum of three antenatal

appointments, and slight decreased median gestational age at first antenatal care visit.

Partner accompaniment to antenatal care was associated with higher odds of health facility

delivery, but little difference in odds of anti-retroviral treatment initiation (Audet et al.,

2016).

Benefits of CHW engagement include their familiarity with local issues, existing

rapport with community members, and circumvent the problem of a scarcity of other

human resources. Becker and colleagues (2014) reported on the utilization of a pair of

CHWs in Malawi to provide family planning and or HIV counseling and testing in a single

home visit to couples. They reported that more than 75% of the women and men visited by

CHWs subsequently received their first HIV test and about 60% of couples tested

26
subsequently reported they discussed the results of their HIV test as a couple. The results

also indicated a significant increase in condom use during the most recent sexual

intercourse, and there were no reported incidents of serious violence among any of the

couples at the one-week follow-up visit. In a similar study in Malawi, women who received

couples counseling training were more likely to have their partners present during

subsequent counseling and to receive condoms at their first family planning visit (Lemani

et al., 2017).

Other reported outcomes of CHW interventions include improved community

perception, acceptability and utilization of obstetric care among couples (Mushi et al.

2010). Mushi and colleagues used community-based safe motherhood promoters to

improve the utilization of obstetric care in a rural district of Tanzania. Findings included a

significant increase in early antenatal booking by primigravida mothers, in the number or

primigravida women attending at least one antenatal visits and in the proportion of women

who delivered with skilled attendants. In addition to antenatal care attendance at least once

during pregnancy by all the women, the number of respondents who were able to mention

at least three pregnancy risk factors and cite at least three practices that contribute to delay

in seeking obstetric care increased signficantly (Mushi et al. 2010). In Tanzania, CHWs

delivered a Home-Based Life Saving Skills training for pregnant women. The CHWs made

a minimum of four visits to the family during the period of the woman’s pregnancy.

Women who received the CHW visits had increased levels of knowledge of potential

danger signs during pregnancy, childbirth, and postpartum. Also, a higher proportion of

men accompanied their partner/wives to prenatal care visits and a higher proportion of

27
women were involved in shared decision-making about place of delivery (August et al.,

2016).

Given that CHWs are trained to provide the culturally and context‐specific

advocacy and engage in the reciprocal exchange of information within familial social

contexts, these findings are not surprising. CHWs serve as vital links, bridges, and in‐

between people, brokering between the world in which they and their neighbors live and

the healthcare system (Norris et al., 2006). Similar results were reported in CHW-delivered

family planning intervention studies in Malawi and in Ethiopia. A Randomized Controlled

Trial on couples’ family planning communication in Malawi used five visits to provide

information, motivation, and behavioral skills to intervention group particpants. The

intervention was delivered by a male motivator over 6 months. As compared to the control

group, intervention group participants reported a significant increase in contraceptive use,

in ease and frequency of discussing family planning with their partners, the use of joint

process for deciding to use family planning, and reduced differential couple

communication (Hartmann et al., 2012). The authors added that the frequency with which

men discussed family planning with their wives was a significant predictor of family

planning uptake. Tilahun and colleagues (2015) measured spousal communication and

family planning uptake among couples in Ethiopia. They reported a positive association

between the intervention and use of contraception among those who were not using

contraceptives at baseline, and higher levels of husbands’ involvement and spousal

discussion on family planning. However, no significant difference in contraceptive use was

found between the intervention and control arms. These findings provide further evidence

that CHWs programs may be more successful in community‐based, participatory models,

28
in which community members and healthcare and other agencies have shared values,

equity, planning and participation (Norris et al., 2006).

In all ten of these studies, regardless of the type of reproductive health program,

intervention strategy, or duration of intervention, male involvement in couples-orientated

programs was efficacious. Three studies employed formal written invitation letters to

incentivize male participation in women’s reproductive health (Jeffreys et al., 2015;

Byamugisha1 et al., 2011; Bright et al., 2011). In Tanzania, Jeffreys and colleagues (2015)

used written invitations to motivate male partners to attend joint antenatal care and couple

voluntary counselling and testing. They reported 81% of the couples that attended a joint

antenatal care session received voluntary couple counselling and testing, and 71% reported

an improved relationship between with their partner. Beyond improved couple

communication and support, 96% of the women noted improved decision-making

regarding antenatal care, family planning and sexual and reproductive health (Jeffreys et

al, 2015).

Similarly, in Uganda, Byamugisha and colleagues (2011) reported the positive

effect of written invitation letter on couple antenatal attendance and partner acceptance of

HIV testing. More than 90% of males who attended the antenatal clinic visit with their

wives accepted HIV counselling and testing. Similarly, in Nigeria, male partners of

antenatal attendees who accepted an invitation to be part of a three-day participatory

training on female reproductive health and family planning showed a remarkable increase

(90%) in knowledge of methods of contraception and a higher proportion of men who

expressed intent to use family planning in the future. At follow-up with 50 couples, all

29
male participants reported improved spousal communication on family planning (Bright et

al., 2015).

Interventions designed for men-only

There were seven examples of interventions delivered exclusively to men, without

the presence of partners or spouses (Adeleye, Aldoory & Parakoyi, 2011; Exner et al.,

2009; Ghanotakis et al., 2016; Shattuck et al., 2011; Adeleye & Okonkwo, 2016; Okigbo,

Speizer, Corroon, & Gueye, 2015). The content of these programs included family

planning, birth preparedness, dual protection from HIV/STI, and maternal health

improvement. Assessment of these interventions examined the level of men’s participation,

their adoption of the specific intervention, and level of spousal influence on the adoption

of the intervention by their wives. Various approaches to engage men were employed,

including peer-delivered interventions, male-friendly clinics, and active engagement of

community leaders. There is increasing recognition of the power and influence of peer

education in health promotion and illness prevention.

Peer-delivered educational interventions are important to involve and engage men

in reproductive health initiatives given the complex nature of relationships and societal

pressures. The reported peer-led interventions resulted in greater positive changes in

contraceptive uptake, and HIV service uptake. For example, post-assessment of a peer-

delivered educational intervention designed to encourage contraceptive use among

Malawian men and to foster communication about family planning with their partners,

demonstrated a significant increase (78%) in male intent to use family-planning methods

among men in the intervention arm compared to 59% in the of the comparison arm.

Additionally, a significant increase using family-planning methods with their wife and

30
intended to continue for 2 years; and overall communication about family planning with

their partner (Shattuck et al, 2011).

Similarly, in Uganda, peer educators delivered a community-based intervention to

improve family planning, HIV service uptake, and transform harmful gender norms

(Ghanotakis et al., 2016). Men who received the intervention reported higher levels of

seeking clinic services for self, condom use with main partners over the past three months,

having an HIV test, communicating with main partners on family planning method, and

accompanying a partner to the clinic in the past five months (Ghanotakis et al., 2016).

Given the wide recognition of peer education as an approach in communicating behavioral

changes especially in addressing HIV pandemic, these findings are not surprising (Harris,

Smith & Myer, 2000). Furthermore, health education and outreach by peers, community

health workers, and local community and religious leaders are cost-effective community

health promotion strategies that utilize local human resources.

Community and religious leaders are vital community members in Sub-Sahara

Africa, where collectivism is a way of living and community leaders’ opinions are an

important factor in women’s utilization of health services (Chigbu, et al., 2013). These

leaders are key stakeholders who can effect changes through advocacy, effective

mentorship, policy change, and seeking the support of benevolent community members

and organizations to improve community resources. Male community leaders in Nigeria

were motivated to act as change agents and encouraged other men to assist with maternal

health in their community after being engaged in group health talks to improve maternal

health (Adeleye, Aldoory, & Parakoyi, 2011). Okigbo and colleagues (2015) reported

similar findings in their assessment of a family planning program that was positively

31
associated with men reporting increased use of modern contraception in Kenya, Nigeria

and Senegal. The program involved religious leaders in television programs, print media,

and community events aimed at increasing men’s exposure to family planning messages

and modern contraceptive use.

Furthermore, Nigerian men who had female partners were mobilized to increase

dual protection against HIV/STI, which produced notable outcomes. The participants were

one-third less likely to engage in unprotected sex in the prior 3 months, approximately four

times more likely to report condom use at last sexual intercourse with their main partner,

and approximately seven times more likely to correctly identifying venues for HIV testing.

Additional outcomes included: men’s partners were 10 times more likely to have been

tested for HIV/STI, the men had lower expectations that condoms would be associated with

a negative response in the context of their primary relationship, and the men held

significantly less stigmatized beliefs about HIV-infected people (Exner et al., 2009).

Male engagement in healthy sexual behaviors is essential to ensure the sexual and

reproductive health of women, girls, and families. Men are increasingly encouraged to

participate in improving maternal health because of their role as family gatekeepers. An

educational session on maternal deaths among married men in Nigeria showed large

improvement in their knowledge of family planning methods for females, facilities for

antenatal care and delivery, and key warning signs of maternal death (Adeleye &

Okonkwo, 2016). Additionally, there was increased willingness to provide money and

encourage partners to seek care. One of the key strategies to reduce maternal death and

increase safe motherhood is birth preparedness (Acharya, Kaur, Prasuna, & Rasheed,

2015). Birth preparedness includes knowing danger signs, planning for a birth attendant

32
and birth location, arranging transportation, identifying a blood donor, and saving money

in case of an obstetric complication (Acharya, Kaur, Prasuna, & Rasheed, 2015). Although,

Ibrahim et al., (2014) reported that a behavioral intervention had no statistically significant

impact in the levels of birth preparedness among married men in Nigeria, they did observe

other positive behavioral changes among husbands who participated. These behavioral

changes included: encouraging their wives to attend antenatal clinic, accompanying their

wives to the clinic, reducing their wives’ household chores, taking care of their wives’

basic needs, granting their wives permission to seek health care when ill, taking their wives

to the health facility when ill, donating blood when it was needed, and regularly providing

traditional medicine for their wives (Ibrahim et al., 2014).

It is important to note that one way to reach men is to provide strong encouragement

for women to share key health messages and information with their partners. Indirect

involvement of men may be a way to enhance maternal health in Africa. For example,

Zamawe, Banda, and Dube (2015) assessed the impact of a maternal health mass media

campaign aired in Malawi and found a significant relationship between women’s exposure

to the radio campaign and an increased likelihood that their husbands were involved in

maternal health issues, including participating in antenatal care, being involved in

childbirth and participating in postnatal care.

Discussion

This review presents the current state of the science related to male involvement

in reproductive health interventions in Sub-Saharan Africa from 2007 to 2018. The salient

findings indicated male involvement is a feasible and effective strategy for improving

family planning usage, utilizing maternal health services, participating in HIV counselling

33
and testing, changing some harmful gender-based norms, and reducing risky sexual

behaviors. There is clear evidence from the existing research that male community and

religious leaders are willing to be advocates and change agents and involved in women’s

health issues. Therefore, it is important that reproductive health programs are adapted to

and organized in line with the community local culture to enhance acceptance, adoption

and utilization. In most Sub-Saharan nations, individuals are strongly engrained in social

and cultural practices, norms, and expectations, which limits control and freedom for self-

expression, requiring submissiveness, especially from women and girls. This gender power

inequality plays a role in sexual and reproductive health.

The findings from this review showed that men are willing to participate in

reproductive health programs, which contradicts the stereotypically assumptions and

perception that African men are often uninterested in reproductive health and that

reproductive health responsibilities are solely the role of a woman (Chipeta, Chimwaza &

Kalilani-Phiri, 2010). Men are important partners in reproductive health, considering the

increasing emphasis on social determinants of health. The socio-cultural factors, especially

in relation to gender inequality, in developing countries makes this review very vital for

health providers, program planners and health organizations to be actively engaged in

creating and sustaining initiatives to include men in women’s health promotion. Based on

the literature analyzed, increased and enhanced male participation will support women’s

health choices and encourage shared decision making.

This analysis showed that irrespective of the duration of intervention, involving

men in various reproductive health programs is an important strategy in improving family

planning knowledge and uptake, HIV knowledge, counselling and testing, maternal health

34
services use, spousal communication. In addition, involving men in reproductive health

programs reduced risky sexual behaviors and lessened their beliefs and reported behaviors

some harmful gender-based norms. The increased positive outcomes observed in this

analysis may be due to increased willingness and participation among the participants

which potential explains the improved retention of key messages, increased acquisition of

behavioral skills, increased communication among partners/couples and increased men’s

accompaniment. Increased knowledge about sexual health is associated with attitude

changes, which have been shown to influence behavior and practice (Davidson et al. 1985).

These findings corroborate others’ reports that providing men with information on healthy

maternal and reproductive health practices may encourage both the men and women to

adopt the behaviors, increase use of services, and support partners’ choices (Onyango,

Owoko, & Oguttu, 2010; Steinfeld et al., 2013; Wambui, Ek, & Alehagen, 2009).

Furthermore, there is clear evidence that the mobilization of men as partners in

reproductive health is very vital in reducing the spread of sexually transmitted infections.

Men who participated in the HIV/STI interventions were more likely to have higher safe

sex self-efficacy, use condoms and be tested for HIV/STIs. This review is especially

pertinent in Sub-Saharan Africa, where evidence suggests that many women are

contracting STIs such as HIV within the context of their primary relationships (Hirsch, et

al., 2007). The observed changes could be due to increased knowledge of the risk of unsafe

sexual practices on men and their partners and changes in attitude. The degree to which

these male participation interventions improved reproductive health depended on many

factors such as the number and type(s) of interventions implemented, the implementation

strategies, the quality of implementation, the type of outcome indicator(s) and the outcome

35
measures. As observed in this review, increased contact is very important in increasing the

effectiveness of reproductive health interventions as almost all the studies had at least three

contacts with the participants, which were mostly the initial contact, continuing visits and

follow up contact. This is in line with the recommendation by WHO (2003).

This review highlights the fact that male involvement can be enhanced through

home-based intervention delivery, friendly facility-based service delivery, and engagement

with trained CHWs. It is well known that CHW engagement and the provision of home-

based services are effective strategies to expand coverage and increase accessibility and

availability of services to people living in resource–constrained areas (Mushi et al., 2010;

Audet et al., 2016). These approaches are necessary in Sub-Sahara Africa, where a large

proportion of the low-income populations live more than one hour away from a health

facility (Pearson & Shoo, 2005). This finding corroborates other studies that used trained

CHWs to improve maternal health outcomes (Homer et al., 2014; Lane & Garrod, 2016).

It is important to note that findings from this review suggest that men’s involvement

may not significantly impact certain indicators of reproductive health interventions, such

as birth preparedness, and widespread gender-based norms (i.e., equal decision-making

power) in Sub-Saharan Africa. Interestingly, regardless of the lack of significant difference

with the primary outcome measures reported in few of the studies, there were positive

changes in other contributing factors like freedom to access care, increased spousal

communication and financial and emotional support. Several confounding factors may

inhibit the outcome of an intervention, which may not have been considered during the

planning phase. These include the type of marriage/relationship, educational levels,

financial capabilities of individuals, families, and communities, and religious beliefs. For

36
example, a clear evidence of religious barriers to male involvement in birth preparedness

was observed by Ibrahim and colleagues (2014). In addition, polygamous marriages or

non-cohabiting relationships may contribute to limited success of birth preparedness as

men in these contexts may have competing needs or be less engaged with expectant

mothers. The lack of significant effects on birth preparedness may also be a consequence

of lack of spousal communication and lack of couples’ joint antenatal attendance, thus

resulting in limited exposure of men and women to the benefit of birth preparedness. These

findings suggest that others socio-demographic barriers must be considered when

involving men in interventions to promote birth preparedness.

This review corroborates other calls for the recognition of the importance of men’s

involvement in reproductive health, especially in developing nations. Given the evidence

that men’s involvement in reproductive health programs contributes to positive health and

social impacts, it is important to create and implement specific strategies aimed at

enhancing the involvement of both men and women in reproductive and family health

initiatives and in informing policy recommendations and programmatic planning to

improve reproductive health in Sub-Saharan Africa.

Limitations and Recommendations

To our knowledge, this is the first review to examine the effects of male partners

participation in reproductive health interventions in Sub-Sahara Africa and therefore is an

important contribution to the literature. These findings are limited to the available literature

accessible through major search engines within the past eleven years (2007 – 2018). Other

limitations include the exclusion of all literature published in languages other than English

and research that did not employ an experimental design. The decision to exclude non-

37
experimental designs reflected the aim of exploring the impact of men’s engagement in

reproductive health issues. Thus, the review is restricted to an assessment of men’s

participation in reproductive health. Another potential limitation is that a single author

reviewed the individual papers for inclusion into the review.

These findings do provide the basis for several recommendation for future research

on male involvement in reproductive health in Africa and in developing nations. Further

research on male knowledge, attitudes, and involvement in reproductive health issues and

interventions within Sub-Sahara Africa clearly is warranted. Further research is needed to

support scale up of the best practices for involving men in further reproductive health.

Other area for further research include the assessment of specific mechanisms aimed at

enhancing male participation in reproductive health initiatives.

Conclusion

The evidence provided in this review clearly supports the recommendation that

involving men in reproductive health is essential to improving the health of women, men,

and families in Sub-Sahara Africa. There is clear evidence of the individual, family, and

community benefits of involving African men in reproductive health programs and

services. Involving men should not be limited to reproductive health programs and services

but also incorporated into efforts related to cervical cancer prevention, poverty alleviation,

and infant/child nutrition. Reproductive health programs should be gender comprehensive

and context-specific by bringing men to the table as equal partners rather than considering

their presence as a barrier. More research is warranted to support and strengthen the

findings of this review and to build evidence to support the sustainability and scaling-up

of male participation interventions in various health programs.

38
 CHAPTER 3

EFFECT OF A COMMUNITY-BASED EDUCATIONAL INTERVENTION ON

AWARENESS, KNOWLEDGE AND INTENTION TO TAKE HPV VACCINATION

AND CERVICAL CANCER SCREENING IN NIGERIA.

39
Introduction

Worldwide, human papillomavirus (HPV) infection is the most common sexually

transmitted viral infection of the reproductive tract. HPV infection is so common that the

majority of sexually active men and women will be infected with at least one type of HPV

at some point and may have recurrent infections (Center for Disease Control [CDC], 2017).

Globally, the prevalence of HPV infection in women is 11–12%, with a much higher rate

of 24% in Sub-Saharan Africa (Forman, et al., 2012). At least 20% of women with normal

cervical cytology in Sub-Saharan Africa are infected with carcinogenic HPV genotypes

(De Vuyst et al., 2013). Nigeria is among the Sub-Saharan nations with high rates of HPV-

related diseases (Bruni, et al., 2018). Although there are currently no specific estimates of

HPV prevalence among the general population in Nigeria, available data from various

studies conducted in different cities and states indicate a high prevalence of HPV among

women. For example, a seroprevalence of 42.9% for IgG antibodies to HPV was reported

among women attending the reproductive health clinic in Zaria, a city in the northern

region (Aminu et al., 2014). Other researchers reported HPV infection rates of 30.4% and

36.5% among women who attended the outpatient clinics of a university teaching hospital

in Lagos, South-West Nigeria (Adegbesan-Omilabu, 2014; Okunade, et al., 2017).

Clinical challenges to identifying and tracking HPV infection include the fact that

it is difficult to detect the point at which an individual first became infected with HPV due

to the fact that the infection is asymptomatic, and symptoms often only develop many years

following initial infection (CDC, 2017). Although most HPV infections will clear without

medical intervention, individuals who contract persistent high-risk HPV types may

eventually develop cancer (CDC, 2017). Cervical cancer is by far the most common HPV-

40
related cancer, as nearly all cases of cervical cancer can be attributable to HPV infection

(CDC, 2017). Cervical cancer is the second most common cancer among women in

Nigeria (Ferlay et al., 2014). Cervical cancer morbidity and mortality is high in Nigeria,

where an estimated 14,000 women are diagnosed annually with cervical cancer, and an

estimated 26 women die every day of cervical cancer (Ogundipe, 2013). The reported age-

specific rate of cervical cancer in three states (Ibadan, Abuja, Calabar) were 36.0, 30.3, and

21.0/100,000 among women 15 years of age and above; (Jedy-Agba, et al., 2012; Ekanem,

et al., 2016). It is evident that cervical cancer is a disease affecting many women who may

still be giving birth, raising children and supporting the family financially.

HPV vaccines is projected to eliminate approximately 70% of cervical cancers and

once-in-a-lifetime screening, performed by women in their 30s or 40s could reduce the risk

of cervical cancer by 25 to 30% (WHO, 2014). Although the widespread availability and

uptake of HPV vaccine and cervical cancer screening has significantly contributed to the

declining incidence and mortality of HPV infection and cervical cancer in developed

countries (Cuzick, et al., 2008), this is not the case in developing countries. Similar to the

situation in many developing countries, the rates of HPV vaccination and cervical cancer

screening in Nigeria are not known but presumed to be extremely low (Ndikom & Oboh,

2017; Ogochukwu et al., 2017). Reports from recent investigations indicate fewer than

14% of adolescent girls had received HPV vaccine (Ndikom & Oboh, 2017; Ogochukwu

et al., 2017) and less than 10% of women have been cervical cancer screening (Idowu,

Olowookere, Fagbemi, & Ogunlaja, 2016; Wright et al., 2014). Of particular note, Awodele

and colleagues (2011) also reported poor uptake of cervical screening among nurses, with

60% of the sample of 200 nurses reporting never having been screened for cervical cancer.

41
 Amplifying this low uptake of cervical cancer screening in Nigeria are a wider

range of personal, social, political and institutional factors. Commonly reported barriers

include lack of awareness, poor knowledge of diseases and preventive measures, lack of

spousal support, misperceptions, stigma and modesty, cultural beliefs and practices, cost

of screening, access to and use of health facilities (Adetule, 2016; Lim & Ojo, 2017;

Ndikom & Ofi, 2012; Ezeonwu, 2014; Modibbo et al., 2016). Furthermore, a woman’s risk

of contracting HPV infection and subsequently developing cervical cancer depends not

only on her own sexual behaviors and practices, but also on those of her male partner(s).

The importance of involving men in reproductive health programs has gained increasing

appreciation since the mid-1990s, given the recognition of the impact of sociocultural

factors on women’s reproductive health. Men play significant roles in reproductive health

through their sexual behaviors, emotional support, family decisions and control of family

resources.

Health education is an effective method of increasing awareness, knowledge, and

utilization of HPV vaccination and cervical cancer screening services (Chigbu, Onyebuchi,

Onyeka, Odugu, & Dim, 2017; Gana, Oche, Ango, Raji, & Okafoagu, 2016; Mbachu, Dim,

& Ezeoke, 2017). Lack of awareness and knowledge and persistent misconceptions about

HPV infection and cervical cancer may contribute to lower levels of perceived

susceptibility and reduced uptake of the preventive measures (Becker, 1974). Interventions

such as community outreach activities, educational fairs, individual mailings, telephone

calls and health care provider reports have been designed to improve HPV vaccination and

cervical cancer screening in different populations and at various levels (Falk, 2018;

Okasako-Schmucker, et al., 2018; Kester, et al., 2014; Krawczyk, et al., 2012). Some

42
studies have evaluated community-directed cervical cancer screening interventions in

Nigeria (Abiodun et al., 2014; Odunyemi, Ndikom, & Oluwatosin, 2018). A community

health education nurse-directed 2-day workshop on cervical cancer and HPV vaccination

reported very significant increases (mean score 9.6 ± 7.2 to 21.5 ± 6.2, p<.05) in

knowledge, and more than 93% of mothers who participated were ready to accept HPV

vaccination for their adolescent daughters (Odunyemi, Ndikom, & Oluwatosin, 2018).

Another community-based intervention involving adult women in rural communities

utilized multiple mediums including structured health education, didactic lectures, a movie

and a handbill (pamphlet) to increase awareness of cervical cancer and cervical cancer

screening by 83.1% (Abiodun et al., 2014).

The assessment of the effectiveness of different educational strategies is pertinent

as many health interventions deemed cost-effective are not affordable in developing

countries because of resource limitations (Bilinski, et al., 2017). Adopting low-cost

interventions that maximize health returns is essential in low resource settings. Increasing

universal coverage for interventions with high potential population health benefits is

imperative in public health planning and implementation, especially for low resource

settings, and residents in hard to reach areas. Prior research has shown that increasing

awareness and knowledge of HPV, HPV vaccination, and cervical cancer, and cervical

cancer screening has been effective in increasing both behavioral intention and behavior.

Our aim was to implement an educational intervention, using two strategies, one that could

be efficiently delivered to groups in natural settings such as churches, and one that could

be delivered to individuals who may not be accessible in group settings. Based on the

assumption that some members of the target population would be more accessible and/or

43
amenable to a group interventions and others to an individual intervention, two different

intervention strategies that delivered the same content were employed to maximize

population reach. To our knowledge, to date no study has evaluated the efficacy of two,

low cost interventions for improving HPV vaccination and cervical cancer screening in

Nigeria. Therefore, the aim of this research was to evaluate the preliminary efficacy of two

different community-based health education intervention strategies, aimed at improving

awareness and knowledge of: (1) HPV, HPV vaccination, cervical cancer, and cervical

cancer screening, and (2) intention to take and or encourage HPV vaccination and cervical

cancer screening among urban adults in Nigeria.

The research site was Anambra, the eighth most populated state in Nigeria.

Anambra residents have high literacy rates. The state is a highly-urbanized state with 62%

of its population living in urban areas. It is located in the southeastern Nigeria, within an

area of 1,870 mi², and a has a total of 5,366,900 (2013 estimate) inhabitants (National

Population Commission of Nigeria, 2015). The educational interventions and data

collection occurred from December 2017 to January 2018.

Method

This study employed pre-test and post-test design to evaluate the effectiveness of a

community-based health education intervention, a face-to-face presentation delivered in

group settings and printed pamphlet delivered to individuals. Both intervention strategies

involved men and women.

Participants. The study participants were men and women who met the inclusion

criteria and volunteered to participate. The inclusion criteria were adults between the age

of 18 and 65 years who were able to read and write in English. Participants who received

44
the face-to-face presentation (Presentation Group), and participants who received a printed

pamphlet (Pamphlet Group) were allocated to groups using convenience sampling based

upon setting, access, and individual preference. Participants recruited in large groups (e.g.

churches, organizations) received face-to-face group-based education while participants

recruited in single groups (e.g., large extended families) or alone received printed

pamphlet-based education. Participation was voluntary and participants in both groups

were given option to choose or reject either of the interventions. Only participants who

completed the pre- and post-intervention surveys were included in the final analysis. A

sample size of 200 participants were estimated. To account for possible attrition, 281

participants were recruited; 168 participants were recruited for the Presentation Group and

113 participants were recruited for the Pamphlet Group.

To recruit participants, individual contacts were made with priests, lay leaders, and

head of organizations, informing them of the study. Churches have been used effectively

in health promotion interventions in communities in Nigeria, where faith has a substantial

role with 87% of people reporting religious service attendance at least once a week

(Ezeanolue, et al., 2015; Ucheaga, & Hartwig, 2010; Abanilla, et al., 2010). At other sites

(e.g., hospitals, educational institution), the primary investigator approached individuals,

and after verifying they met the inclusion criteria, extended an invitation to participate. A

detailed explanation of the objectives, eligibility criteria, confidentiality, and the voluntary

nature of study participation was done. All participants completed the paper-based, self-

administered pre- and post-surveys. Verbal informed consent was obtained, given that it is

more culturally acceptable and appropriate than written consent in Nigeria. Human subject

protection approval was received from the University of South Carolina Institutional

45
Review Board for which the primary investigator was affiliated. All data were collected

in a span of four weeks from December 2017 to January 2018.

Intervention. The face-to-face presentation and printed materials were developed

from available educational resources on the Center for Disease Control and Prevention

(CDC) and the Foundation for Women’s Cancer websites (CDC, 2017; Foundation for

Women’s Cancer, 2017). The educational content and presentation materials were adopted

and modified by the primary investigator, a native Nigerian, to be culturally- and

environmentally relevant to the target population. Both modalities had the same content

which included: information on the HPV, HPV vaccine, cervical cancer and cervical cancer

screening, statistical facts on incidence and prevalence of HPV and cervical cancer in

Nigeria as well as the rate of HPV vaccination and cervical cancer screening, and common

misconceptions about HPV, HPV vaccination, cervical cancer and cervical cancer

screening.

The intervention design included three phases. The pre-intervention phase was the

administration of baseline information using the questionnaire. The intervention phase

involved the administration of the health education intervention, in the form of either a

face-to-face health presentation or a printed pamphlet. The total time (including pretest,

intervention and posttest) for participants who received face to face presentations ranged

between 40 and 60 minutes, whereas study participation time for those who received the

pamphlet ranged from 20 to 80 minutes. Among both groups, the post-intervention phase

involved re-administration of the questionnaire immediately following the educational

intervention.

46
 Survey Instrument. A questionnaire previously developed and used to assess

awareness, knowledge, attitude and practice of HPV and cervical cancer preventive

measures among 352 men in Nigeria was adopted and modified. Survey questions were

based on and/or adapted from other existing surveys, including the Cervical Cancer Free

Coalition National Surveys; Health Information National Trends Survey and previous

studies on HPV and cervical cancer among men in sub-Saharan Africa (Maree, Wright, &

Makua, 2011; Rosser, Zakaras, Hamisi, & Huchko, 2014; Rwamugira, Maree, & Mafutha,

2017; Williams, & Amoateng, 2012). There were two versions of the English-language

survey, one for men and the other for women. The men’s survey contained 44 questions

and the women’s survey consisted of 47 questions. The three additional questions for

women related to decision making. Each version addressed awareness, knowledge,

attitude, intention and stigma. Question format included 4 open-ended questions and 40

and 43 multiple-choice questions for men and women respectively.

Data Analysis Strategies. Data were manually entered into an excel spreadsheet,

crosschecked for correctness, and subsequently analyzed using Statistical Analysis System

(SAS) software version 9.4. Data analysis consisted of descriptive statistics (mean,

frequency and percentage) for socio-demographic variables. Differences between the

demographic characteristics of the two groups were evaluated using t-test and Chi square

statistics. In regard to knowledge of HPV and cervical cancer, a composite score was

computed for each respondent by assigning a score of 1 to each correct answer and 0 to

each wrong answer. Their level of knowledge was scored and categorized as follows: 0-4

is low, 5-9 is fair, 10-13 is high. Descriptive statistics were used to describe group

frequencies pre-and post-test for each intervention group and changes in pre-post

47
knowledge changes were assessed independently for each group using ANOVA. The

statistical significance was set at p < 0.05.

Results

Of the 266 participants who completed both the pre-intervention and post-

intervention questionnaire, 163 were in the Presentation Group and 103 were in the

Pamphlet Group. Socio-demographic characteristics of the participants are shown in Table

3.1. Significant differences were found between the sociodemographic characteristics of

the groups existed in age, sex, educational level and monthly income (p <0.05). The mean

age of the Presentation Group and Pamphlet Group was 35.6 ± 9.64 years and 38.8 ± 10.8

years respectively. More than half of the participants were women (54.0% Presentation

Group and 61.2% Pamphlet Group) and married (59.5% Presentation Group and 71.6%

Pamphlet Group). There were no significant differences in marital status (p=0.2494)

between the two groups. Overall, participants were well-educated, but fewer Presentation

Group participants (71.6%) reported having college education than Pamphlet Group

participants (84.3%). Despite high educational levels, 55.8% of Presentation Group

participants and 36.0% Pamphlet Group participants reported less than 50,000 Nigerian

naira monthly income (equivalent to $139 in the United States). The analysis of the

demographic characteristics showed that the two groups were different, therefore their

knowledge and intention to take HPV vaccine and Cervical Cancer screening were

analyzed separately.

Data on HPV and HPV vaccine knowledge and are presented in Table 3.2. The

groups will be analyzed separately because the participants differ in many of their baseline

characteristics. Only participants who took the pre and posttest were included in the

48
analysis. There are differences in the number of responses per item because participants

who had never heard of HPV were told to skip the other HPV knowledge questions.

Table 3.1: Summary of Participant Demographics

Characteristic Presentation Pamphlet t-test
Group n (%) Group n (%)
Age, years (mean+SD) 35.6+9.64) 38.8+10.8 0.0168
Age group (years)
18 -24 5 (3.14) 3 (2.94) 0.0370
25 - 34 71 (44.7) 43 (42.2)
35 - 44 57 (35.9) 23 (22.6)
45 - 54 18 (11.3) 23 (22.6)
55 and above 8 (5.03) 10 (9.80)
Sex
Men 75 (46.0) 40 (38.8) 0.0427
Women 88 (54.0) 63 (61.2)
Marital status
Single 66 (40.5) 29 (28.4) 0.2494
Married 97 (59.5) 73 (71.6)
Educational level
No formal education 0 (0.00) 0 (0.00) 0.0614
Primary education 3 (1.85) 2 (1.94)
Secondary education 43 (26.5) 14 (13.7)
Tertiary education 116 (71.6) 86 (84.3)
Monthly income
Less than #50, 000 86 (55.8) 36 (36.0) 0.0054
#50-100,000 34 (22.1) 32 (32.0)
Above #100,000 34 (22.1) 32 (32.0)

For the Presentation Group, at pre-intervention, 17.8% of respondents had heard of

HPV infection, whereas on the post-test, 91.4% reported knowledge of HPV infection, and

23.3% knew that HPV is a sexually transmitted virus, with a statistically significant

difference (p < 0.05). Also, less than one-fourth of participants reported knowing that men

and women can contract HPV infection prior to the intervention, whereas at post-

intervention, more than 82% reported knowledge. At baseline, level of awareness of HPV

49
vaccine was 11.8%, which rose to 88.8% at post intervention, with a statistically significant

difference (p<0.05).

About 27.2% of Pamphlet Group respondents had heard of HPV infection at

preintervention, whereas on the post-test, 98.1% reported knowledge of HPV infection

(p < 0.05), as shown in Table 3.2. At baseline, 35.0% knew that HPV is a sexually

transmitted virus, while 98.1% participants reporting awareness of HPV at postintervention

(p < 0.05). Prior to the intervention, 25% of the participants reported knowing that men

and women can contract HPV infection, whereas at post-intervention, more than 82%

reported knowledge. The level of awareness of HPV vaccine was 20.4% at baseline and

increased 85.4% at postintervention (p<0.05).

Table 3.3 presents findings related to participants’ knowledge of cervical cancer

and cervical cancer screening. Similar to HBV knowledge, the two groups were different

at baseline and, therefore, the groups were analyzed separately. The proportion of

Presentation Group participants at pre-intervention, who had heard of cervical cancer was

64.2% and rose to 93.8% at post-intervention (p <0.05). About 36.8% reported knowing

that smoking and multiple sexual partners increases the risk of getting cervical cancer at

baseline, which increased to more than 65% knew post intervention (p < 0.05). Only 25.8%

of Presentation Group participants knew cervical cancer is associated with HPV infection

at baseline, and at post-intervention, more than 85% of participants were aware that

cervical cancer is associated with HPV infection with a significant difference of (p < 0.05).

Additionally, at pre-intervention, among the Presentation Group participants only 13% and

14.9%, respectively had heard of about the pap smear test or VIA, which were statistically

significant (p <0.05) at post-intervention.

50
Table 3.2. Participant Knowledge of HPV and HPV Vaccine Pre- and Post-Intervention
Variables Presentation Group n (%) Pamphlet Group n (%)
Pre Post p Pre Post P
Have you ever heard
of HPV? No 112(68.7) 8(4.91) 66(64.1) 1(0.97)
Yes 29(17.8) 149(91.4) <.0001 28(27.2) 101(98.1) <.0001
Not sure 22(13.5) 6(3.98) 9 (8.74) 1(0.97)
How do you think
one can get HPV?
Physical contact 6(5.83) <.0001
Dirty toilets 6(3.68) 17(10.6) <.0001 2(1.94) 4(3.88) 0.0034
Poor personal 12(7.36) 13(7.98) 0.4505 1(0.87) 3(2.91) 0.0678
hygiene 16(9.60) 18(11.0) 0.4670 2(1.94) 101(98.1) <.0001
Sexual intercourse 38(23.3) 151(92.6) <.0001 36(35.0)
How do you know
when someone has
HPV?
Itching
Pain during 18(11.0) 151(92.6) <.0001 10(9.71) 101(98.1) <.0001
urination 10(9.71) 25(15.3) 0.0002 4(3.88) 10(9.71) 0.0152
Genital discharges 15(9.20) 37(22.7) <.0001 14(13.6) 50(48.5) <.0001
Genital rash 16(9.82) 13(7.98) 0.4180 12(11.7) 19(18.5) 0.0396
No symptoms 10(6.13) 103(63.1) <.0001 13(12.6) 33(32.0) <.0001
Who can contract
HPV?
Male only 0(0) 0(0) 9(8.87) 2(1.94)
Female only 11(6.74) 6(3.82) 9(8.87) 13(12.6)
Male and female 41(25.2) 151(96.2) 0.0016 26(25.2) 85(82.5) <.0001
What factors
increase the risk of
getting HPV?
Poor diet
Smoking 6(3.68) 5(3.07) 0.2124 0(0) 2(1.94) <.0001
Poor personal 7(4.29) 41(25.2) <.0001 11(10.7) 48(18.1) <.0001
hygiene Multiple 16(9.82) 25(15.4) 0.0024 3(2.91) 5(4.85) 0.0612
sexual partners 39(23.9) 147(90.7) <.0001 33(32.0) 92(89.3) <.0001
Have you heard
about HPV vaccine?
No 133(82.6) 16(9.94) 77(74.8) 9(8.74)
Yes 19(11.8) 143(88.8) <.0001 21(20.4) 88(85.4) <.0001
Not sure 9(5.59) 2(1.24) 5(4.85) 6(5.83)
Who can take the
vaccine?
Boys and girls 14(8.59) 96(58.9) <.0001 15(14.6) 64(62.1) <.0001
Young men and 23(14.4) 103(63.2) 22(21.4) 66(64.1)
women

51
 For participants in Pamphlet Group, the proportion of participants who had heard

of cervical cancer was 71.8% at baseline and rose to 92.1% at post-intervention. At pre-

51.3% of the participants reported knowing that smoking and multiple sexual partners

increases the risk of getting cervical cancer (p < 0.05). however, at post-intervention,

51.5% and 89.3% of the participants knew that cervical cancer is associated with and

infection respectively (p < 0.05).

Also, 67.0% of the participants knew cervical cancer is associated with HPV

infection, and 92.2% became aware at postintervention (p < 0.05). Only 37.9% and 31.1%

respectively had heard of the pap smear and HPV tests; which increased to almost 70% and

were statistically significant (p <0.05). Both community-based educational methods

significantly increased participants’ knowledge of cervical cancer and cervical cancer

screening as shown in Table 3.3.

Participants’ Level of Knowledge of HPV and Cervical Cancer. Table 3.4

shows the respondents level of knowledge of HPV and cervical cancer. In the Presentation

Group 85.3% had poor knowledge, 9.82% had moderate and 4.91% had high level of

knowledge of HPV and HPV vaccine, with significant improvements made at post-

intervention.

Participants in the Pamphlet Group also significantly improved their knowledge of

HPV and HPV vaccine from pre-test to post-test. Those who had high knowledge of HPV

and HPV vaccine increased from 5.88% to 46.6%. In addition, both groups significantly

increased knowledge of cervical cancer and cervical cancer screening as shown below in

Table 3.4.

52
Table 3.3 Knowledge of Cervical Cancer and Cervical Cancer screening Pre-intervention
(Pre) and Post intervention (Post).
Variables Presentation Group n (%) Pamphlet Group n(%)
Pre Post p Pre Post p
Have you ever heard
of cervical cancer?
No 34(21.0) 3(1.86) 25(24.2) 2(1.98)
Yes 104(64.2) 151(93.8) <.0001 74(71.8) 93(92.1) 0.0001
Not sure 24(14.8) 6(5.94) 4(3.88) 6(5.94)
Which of the
following do you
think increases the
risk of getting cervical
cancer? Smoking 40(24.5) 60(36.8) 0.0020 26(25.2) 53(51.5) <.0001
Multiple sexual 62(38.0) 136(83.4) <.0001 71(68.9) 92(89.3)
partners
Do you think cervical
cancer is associated
with an infection? No 51(34.7) 9(5.73) 32(33.0) 8(7.77)
Yes 96(65.3) 148(94.3) <.0001 65(67.0) 95(92.2) <.0001
If yes; what type of
infection is cervical
cancer associated
with? 42(25.8) 140(85.9) <.0001 57(57.0) 92(89.3) <.0001
HPV infection
Cervical cancer be
prevented? No 21(14.2) 3(1.92) 11(10.7) 6(5.83)
Yes 127(85.8) 153(98.1) 0.0201 92(89.3) 97(94.2) 0.0082
Early detection of
cervical cancer is
helpful? No 14(9.21) 6(3.82) 0.0075 6(5.88) 1(1.03) 0.1967
Yes 138(90.8) 151(96.2) 96(94.1) 96(99.0)
Have you heard about
Pap smear test or
Visual Inspection
with Acetic Acid
(VIA)? No 113(69.8) 11(6.75) 55(53.4) 21(20.4)
Yes 21(13.0) 138(84.7) <.0001 39(37.9) 72(69.9) <.0001
Not sure 28(17.3) 14(8.59) 9(8.74) 10(9.71)
Have you heard about
HPV test? No 119(73.9) 12(7.50) 55(53.4) 9(8.74)
Yes 24(14.9) 136(85.0) <.0001 32(31.1) 90(87.4) <.0001
Not sure 18(11.2) 12(7.50) 16(15.5) 4(3.88)
Who can take Pap
smear test or VIA or
HPV test? Women 40(24.5) 137(84.1) <.0001 57(55.9) 92(89.3) <.0001

53
Table 3.4: Participants Level of Knowledge of HPV, HPV Vaccine, Cervical Cancer and
Cervical Cancer screening Pre and Post intervention.
Variables Presentation Group n(%) Pamphlet Group n(%)
Pre Post p Pre Post p
Level of Knowledge
of HPV and HPV
Vaccine.
Poor 139(85.3) 13(7.98) 82(80.4) 20(19.4)
Moderate 16(9.82) 61(37.4) <.0001 14(13.7) 35(34.0) <.0001
High 3(4.91) 89(54.6) 6(5.88) 48(46.6)
Level of Knowledge
of Cervical Cancer
and Cervical Cancer
screening?
Poor 64(39.3) 12(7.36) 21(20.4) 3(2.91)
Moderate 63(38.6) 29(17.8) <.0001 23(22.3) 16(15.5) 0.0002
High 36(22.1) 122(74.9) 59(57.3) 84(81.6)

Reported Uptake of HPV Vaccine and Cervical Cancer Screening at Baseline.

Less than 8% of respondents in both groups had received either the HPV vaccine

themselves or knew of a family member had taken HPV vaccine. Data regarding baseline

uptake of cervical cancer prevention and screening is presented in Table 3.5. As shown,

the number of men and women who had received the HBV vaccination were similar and

there was little difference between groups (p > 0.05). Additionally, very few people in

either group, 5.52% in the Presentation Group and 11.6% in the Pamphlet Group, received

or had a family member who had received a pap smear or VIA test (p > 0.05).

Intention to take and or encourage HPV Vaccine. Table 3.6 presents the study

participants’ intent to receive and or encourage HPV vaccine before and after the

intervention. Participants were asked questions about their willingness to take, encourage

and pay for a family member or their uptake of HPV vaccine. Less than 19% of respondents

in the Presentation group planned to receive HPV vaccine, and only 26.7% were willing to

encourage a family member or friend to receive the HPV vaccine at baseline. At post-

54
intervention, 69.1% planned to receive HPV vaccine, and 85.3% were willingness to

encourage a family member or friend to receive the HPV vaccine (p < 0.05 for both pre-

versus post-test). In addition, participants indicating an intent to pay to receive or for a

family member to get HPV vaccine pre-intervention was 31.3% among Presentation Group

participants and increased to 63.4% with a significant difference (p <0.05).

About 18.5% and 45.6% of respondents in the Pamphlet Groups planned to receive

HPV vaccine and were willingness to encourage a family member or friend to receive the

HPV vaccine, respectively, at baseline. Intentions towards HPV vaccination significantly

increased to more than 53% at post-intervention, which was significantly different from

baseline in (p < 0.05). Similarly, participants intent to pay to receive or for a family member

to get HPV vaccine was 40.8% at pre-intervention and rose to more than 73% at post-

intervention (p <0.05). As shown in Table 3.6, at post-intervention, we observed an

increase in participants’ intent to receive, encourage and pay for HPV vaccine in both

groups.

Table 3.5: HPV Vaccine and Cervical Cancer Screening Rate

Variables Presentation Group Pamphlet Group
n(%) n(%)
Have you or anyone in your family
had HPV vaccine? If Yes, who?
Me 4 (2.45) 2 (1.94)
Wife 2 (1.23) 0 (0)
Daughter 0 (0) 2 (1.94)
Son 0 (0) 0 (0)
Others 2 (1.23) 4 (3.88)
Nobody 147 (91.8) 95 (92.23)
Have you or anyone in your
family done a pap smear or VIA
test? If Yes, who? 6 (3.68) 5 (4.85)
Wife 0 (0.00) 3 (2.91)
Daughter 3 (1.84) 4 (3.88)
Others 149 (91.4) 82 (79.6)
Nobody

55
Table 3.6. Intention to encourage and or take HPV Vaccine.
Variables Presentation Group n(%) Pamphlet Group n(%)
Pre Post p Pre Post P
Do you plan to take
HPV vaccine?
No 51(31.3) 20(12.5) 47(45.6) 23(22.3)
Yes 30(18.4) 112(69.1) <.0001 19(18.5) 55(53.4) <.0001
Maybe 82(50.3) 30(18.5) 37(35.9) 25(24.3)
Will you encourage
your family member
or friends to take
HPV vaccine?
No 15(9.32) 2(1.23) 15(14.6) 12(11.7)
Yes 43(26.7) 139(85.3) <.0001 47(45.6) 7(73.8) <.0001
Maybe 103(64.0) 22(13.5) 41(39.8) 15(14.6)
Who will you
encourage to take
HPV vaccine?
Wife 11(14.7) 45(43.7) 17(10.4) 18(17.5)
Daughter 44(27.0) 106(65.0) 49(30.1) 83(80.6) 0.8185
Son 36(22.2) 103(63.2) <.0001 26(25.2) 74(71.8) <.0001
Others 38(23.3) 72(44.2) 27(26.2) 41(39.8) <.0001
Nobody 80(49.1) 20(12.3) 22(21.4) 8(7.77) 0.0133
Will you pay to
receive or for a family
member to get HPV
vaccine, If the vaccine
cost too much?
No 27(16.6) 11(6.79) 21(20.4) 7(6.93)
Yes 51(31.3) 109(67.3) <.0001 42(40.8) 64(63.4) 0.0007
Maybe 85(52.1) 42(25.9) 40(38.8) 30(29.7)

Intention to take and or encourage Pap smear or VIA. Similar to other survey

items significant increases were noted in both groups’ intention to receive and willingness

to encourage a family member to receive a screening post-intervention (Table 3.7). Among

the women surveyed in the Presentation Group, 37.5% were planning to receive screening,

and the proportion of respondents willing to encourage family member to receive screening

at baseline was 44.8%. These intentions increased significantly within the Presentation

Group at following the educational intervention (p < 0.05). The proportion of participants

56
willing to pay to receive or to pay for a family member to receive a pap smear was 34.0%

at pre-intervention phase, with no significant increase at post-intervention (p > 0.05).

For pamphlet group, 33.3% of the women surveyed were planning to receive

screening, and 51.5% were willing to encourage family member to receive screening at

baseline. However, at post intervention, more than 61% of both participants were planning

to receive screening and were willing to encourage family member to receive screening (p

< 0.05 for both intentions pre- versus post-test). The proportion of participants in the

pamphlet group willing to pay to receive or to pay for a family member to receive a pap

smear was 46.6% at baseline slightly increased (59.2%) at post-intervention, but the

changes was not statistically significant.

Table 3.7. Intention to Encourage and or Take Cervical Cancer Screening.

Variables Presentation Group n(%) Pamphlet Group n (%)
Pre Post p Pre Post P
Do you plan to go for
cervical cancer
screening (Women
only)?
No 23(26.1) 4(4.55) 34(54.0) 15(23.8)
Yes 33(37.5) 74(84.1) <.0001 21(33.3) 39(61.9) 0.0004
Not sure 32(36.4) 10(11.4) 8(12.7) 9(14.3)
Will you encourage
any of your family
member to receive pap
smear? 15(9.20) 3(1.84) 11(10.7) 11(10.7)
No 73(44.8) 138(84.7) <.0001 53(51.5) 81(78.6) <.0001
Yes 75(46.0) 22(13.5) 39(37.9) 11(10.7)
Not sure
Will you pay to
receive or for a family
member to receive a
pap smear; if the test
cost too much?
No 15(9.26) 12(7.36) 22(21.4) 19(18.5)
Yes 55(34.0) 119(73.0) <.0001 48(46.6) 61(59.2) 0.0633
Not sure 92(56.8) 32(19.6) 33(32.0) 23(22.3)

57
 Logistic regression of factors associated with participants’ level of knowledge

of HPV and cervical cancer. The adjusted model for level of knowledge of HPV and HPV

vaccine is presented in Table 3.8. The adjusted model included age group, marital status,

education and income. For the Presentation group, the odds of increased knowledge of

HPV and HPV vaccine at post intervention for participants between age 18-24 years is 18.1

times higher than the odds of increased knowledge of HPV and HPV vaccine for

participants who are 55 years and older, statistical significant difference. Similarly, the

odds of high knowledge of HPV and HPV vaccine for men is 1.17 times higher than the

odds of high knowledge of HPV and HPV vaccine for women with no statistical significant

difference. Also, no significant difference was observed based on the participants’ marital

status, educational level and monthly income.

For the Participants in the Pamphlet group, the odds of increased knowledge of

HPV and HPV vaccine at post intervention for participants between age 45-54 years is 1.45

times higher than the odds of increased knowledge of HPV and HPV vaccine for

participants who are 55 years and older, with no statistical significant difference. The odds

of increased knowledge of HPV and HPV vaccine were not significantly difference among

participants in the Pamphlet group based on the sex, marital status, educational level and

monthly.

Results of the regression analyses (Table 3.9) indicated the odds of high

knowledge of cervical cancer and cervical cancer screening among participants in various

groups. For the Presentation group, the odds of high knowledge of cervical cancer and

cervical cancer screening for participants aged 18-24 is 18.1 times and 5.7 times for

participants aged 45 to 55 than the odds of high knowledge for those who are 55 years and

58
above with significant difference. However, the odds of high knowledge of cervical cancer

and cervical cancer screening were not significantly different among the participants based

on the sex, marital status, educational level and monthly income. Additionally, for the

pamphlet group, the odds of high knowledge of cervical cancer and cervical cancer

screening were not significant among participants based on the age group, sex, marital

status, educational level and monthly income.

Table 3.8: Regression Analysis of Factors Associated with High Knowledge of HPV and
HPV Vaccine.
Presentation Group Pamphlet Group
Odds 95% CI for OR Odds 95% CI for OR
ratio Lower Upper ratio Lower Upper
Age Group
18 - 24 18.0889 2.4854 131.65 1.4530 0.2893 7.2981
25 - 34 3.7556 0.2555 1.6513 3.8089 0.8097 17.9179
35 - 44 2.8739 0.8300 9.9512 3.0244 0.6380 14.3365
45 - 54 5.7819 1.4558 22.9636 2.2758 0.5400 9.5903
55+ (referent)

Sex
Men 1.1667 0.6203 2.1944 1.0025 0.5032 1.9974
Women (referent)

Marital Status
Single 0.7746 0.3936 1.5248 0.5160 0.1987 1.3402
Married (referent)

Education Level
No formal education 0.06190 0.4488 0.0298 0.1696 0.9854
Primary education 0.2146 0.4143 1.4568 2.3555 0.6679 8.3076
Secondary education 0.7769 1.7533 0.7635 4.0261
Tertiary education
(referent)
Monthly income
(Nigerian Naira)
Less ₦50,000 (referent) 0.3634 1.8853
₦50-100,000 0.8277 0.9340 5.0581 0.3768 0.1594 0.8906
Above ₦100,000 2.1735 2.1404 0.9397 4.8752

59
Table 3.9: Regression Analysis of Factors associated with High Knowledge of Cervical
Cancer and Cervical Cancer Screening.
Presentation Group Pamphlet Group
Odds 95% CI for OR Odds 95% CI for OR
Ratio Lower Upper ratio Lower Upper
Age group
18 - 24 1.2511 0.2668 5.8680 0.4377 0.1045 1.8335
25 - 34 1.6448 0.4682 5.7784 4.1428 1.2717 13.4960
35 - 44 2.4658 0.8182 7.4318 1.6761 0.4377 6.4176
45 - 54 5.2721 1.4257 19.4956 1.7647 0.5947 5.2369
55+ (referent)
Sex
Men 0.3842 0.2118 0.6971 0.5259 0.2507 1.1033
Women (referent)

Marital status
Single 1.0247 0.5073 2.0699 0.3154 0.1255 0.7930
Married (referent)

Education Level
No formal education 0.2387 0.06620 0.8607
Primary education 0.8375 0.3487 2.0116 0.01479 0.005176 0.04227
Secondary education 0.3418 0.1812 0.6449 0.6495 0.3468 1.2161
Tertiary education
(referent)

Monthly income
(Nigerian Naira)
< ₦50,000 (referent) 0.9121 0.3537
₦50-100,000 1.2653 0.6081 2.6330 1.4486 0.5181 2.3521
Above ₦100,00 2.3073 0.9897 5.3789 4.0503

Discussion

Given that it is important to increase knowledge of HPV and cervical cancer and

engage as many individuals as possible in healthy behavior, offering differing learning

modalities is very vital to increase the reach of educational interventions in an effort to

improve the overall health of a population. To our knowledge, this is the first study to

assess the effectiveness of a community-based intervention that used two educational

intervention strategies to improve awareness and knowledge of HPV, cervical cancer and

60
the preventive measures and their intention to engage in and encourage HPV vaccine and

cervical cancer screening in Nigeria. Even though, other studies had utilized various

interventions, presumed to be low cost, they delivered more than one low-cost intervention

per participant, included only women, and/or did not recruit participants from various

locations. The majority of the studies were clinic-based, not community-based.

(Odunyemi, Ndikom, & Oluwatosin, 2018; Ndikom, Ofi, Omokhodion, & Adedokun,

2017). One of the studies that utilized a community-based approach, focused on only rural

women, and assessed only cervical cancer (Abiodun, Olu-Abiodun, Sotunsa, & Oluwole,

2014). The recruitment of participants from various locations in this study, increased the

opportunity to reach individuals who are not associated with groups, such as churches.

Our findings indicate that targeted educational intervention strategies may

contribute to increasing knowledge and intended practices related to HPV vaccination and

cervical cancer screening. The findings are of particular significance considering the high

incidence and prevalence of HPV infection and cervical cancer morbidity and mortality in

Nigeria. Given that increased HPV vaccination coverage to a level of about 70% of the

population can substantially reduce the prevalence of HPV infections, cervical

abnormalities and invasive cervical cancer (WHO, 2009); increasing HPV immunization

awareness, knowledge, and intention are critical. Furthermore, a once-in-a-lifetime

screening of women in between 30 and 50 years of age could reduce the risk of cervical

cancer by 25 to 30% (WHO, 2014).

In this research, both educational modalities (face-to-face group presentation and

educational pamphlets) were effective with in Nigerian adults’ HPV awareness, knowledge

and behavioral intent. At baseline, most participants had very low knowledge levels related

61
to HPV infection, cervical cancer, and related preventive measures. Prior research in

Nigeria has indicated low levels of knowledge of HPV and cervical cancer (Jamda, et al.,

2018; Abiodun et al., 2014). In a community-based cervical cancer education initiative

among market women in an urban area of Lagos, Nigeria, Wright, Kuyinu, and Faduyile

(2010) reported that at pre-intervention, over 75% of participants had no knowledge of

cervical cancer pre-intervention. Similarly, Adamu and Colleagues (2012) reported that the

vast majority of the female teachers in Birnin-Kebbi, North-Western Nigeria, who

participated in their study had very low knowledge of cervical cancer at baseline.

Findings from the present study indicated a marked improvement in the proportion

of correct answers to specific questions about the HPV and cervical cancer risk factors,

mode of transmission, symptoms, and methods of prevention and about HPV vaccine and

cervical screening among the participants in both groups after the educational

intervention. More than 82% of the participants in both group correctly answered most

questions. It is important to note that both groups received the same information, but in

different formats (i.e., group presentation or written information). The significant increase

in level of HPV knowledge was similar to other studies carried out in Nigeria (Wright,

Kuyinu, & Faduyile, 2010; Ndikom, Ofi, Omokhodion, & Adedokun, 2017) and other

developing countries (Chang et al., 2013). For example, Adamu, Abiola, and Ibrahim

(2012) noted an improvement of 124.3% in the mean knowledge of cancer of the cervix

score among female teachers exposed to an educational intervention in North-Western

Nigeria (Adamu, Abiola, & Ibrahim, 2012).

Overall, the level of knowledge of participants in both groups improved. In the

Presentation Group, the percentage with poor initial knowledge (85.3%) of HPV and HPV

62
Vaccine was reduced to 7.98% and among the Pamphlet Group, there was a similar

reduction in poor initial knowledge from 80.4% to 19.4%. A statistically significant

increase in those with very good knowledge were observed from a very low 4.91% to

54.6% and 5.88% to 46.6% in the Presentation and Pamphlet Groups respectively.

Likewise, for cervical cancer and cervical cancer screening, the proportion of participants

with good knowledge rose from 22.1% to 74.9% in the Presentation Group from 57.3% to

81.6% in the Pamphlet Group B, while those with poor knowledge reduced from 39.3% to

7.36% and 20.4% to 2.91% in the respective groups. This finding is higher than those

reported by Ndikom and colleagues that indicated at baseline 55% of nurses who

participated in the educational intervention had poor knowledge, 30% had fair knowledge,

and only 15% had high level of knowledge, whereas at post-intervention 26.8% had poor

knowledge, 48.3% had fair knowledge and 33.3% had high knowledge (Ndikom, Ofi,

Omokhodion, Bakare, & Adetayo, 2017). However, in their research on Nigerian market

women, Gana and colleagues (2016) reported that initially less than 10% were aware of the

pap smear but that 34% reported increased awareness following the intervention.

The low levels of awareness and knowledge observed at baseline in this research

may have contributed to reported low uptake of HPV vaccine and cervical cancer screening

among family members. Less than 8% of participants reported having received the HPV

vaccine and only 12% reported having a family member who had a pap smear. These

findings are consistent with the research conducted by Mbamara and colleagues that found

over 85% of the women attending gynecology clinics in a tertiary medical center in South-

eastern Nigeria had never received cervical screening, despite having attended the

gynecology clinics (Mbamara et al., 2011). Various studies had recorded much lower rates

63
of vaccine and screening in different parts of the country. In Abuja, Nigeria, only 1.4% of

mothers reported having a daughter who had received HPV vaccination (Odunyemi,

Ndikom, & Oluwatosin, 2018). Similarly, very low rates (i.e., less than 11%) of cervical

screening service utilization were reported among female health workers in Sokoto (Oche,

Kaoje, Gana, & Ango, 2013), and civil servants in Plateau (Hyacinth, Adekeye, Ibeh, &

Osoba, 2012).

It is important to note that the vast majority of research aimed at assessing the

uptake of HPV vaccination in Nigeria focuses only on girls, despite the fact that the HPV

vaccine is recommended for both boys and girls. Our findings indicated less than 2% of

the respondents reported having a daughter who had been vaccinated and none reported

having a son who had received the vaccine. Odunyemi and colleagues (2018) reported that

85.5% of the mothers they surveyed reported lack of information was a deterrent to having

their daughters take the vaccine. The fact that HPV vaccine frequently is referred to as a

“cervical cancer vaccine” may contribute to limited awareness that the vaccine is also

appropriate for boys. Of note, Jones and colleagues (2016) reported that half of the college

male students were unaware that the HPV vaccine could be given to males. Also, of note,

most published articles in Nigeria tend to address HPV as a virus that causes cervical

cancer, rather than an infection in and of its own right, thus making it seem is only a concern

for women (Odunyemi, Ndikom, & Oluwatosin, 2018; Wright, Kuyinu, & Faduyile, 2010;

Wright, Aiyedehin, Akinyinka, & Ilozumba, 2014).

We also found support for our second objective, which was intention to take and or

encourage HPV vaccine and cervical cancer screening. These findings indicated significant

improvement in reported intent to take and/or encourage HPV vaccination and cervical

64
cancer screening among individuals in both groups. Whereas less than 46% of the

respondents were willing to take and or encourage their family member to receive HPV

vaccine and cervical cancer screening at baseline, approximately 73% of participants were

willing to do so post-intervention. These rates are lower than those reported in a study

among antenatal women in Ibadan Nigeria (Ndikom, Ofi, Omokhodion, & Adedokun,

2017), where at baseline, not less than 70% of their participants reported a willingness to

utilize cervical cancer screening services, more than 85% were willing to utilize the

services post-intervention. Similarly, Odunyemi and colleagues (2018) reported that 73.9%

of the mothers who participated in a 2-day workshop were ready to accept HPV vaccination

for their adolescent daughters at baseline, whereas 93.8% were willing to do so 3 months

post-intervention. Among urban residential women in southeast Nigeria, the majority of

participants were reported to be willing to be screened both before and after the intervention

(Mbachu, Dim, & Ezeoke, 2017). The high rate of acceptance of and willingness to

participate in HPV vaccination observed in that study may be attributed to the predominant

acceptance of routine childhood vaccinations among Nigerian men and women.

Exploratory subgroup analyses suggested that younger participants aged (18-24)

were more likely to know about HPV and HPV vaccine. This may be attributed to their

younger age and possible prior personal exposure to HPV vaccination. Of note, there were

no differences associated with marital status, levels of education, or monthly income. In

contrast, Mbachu and colleagues (2017) reported no significant associations between

difference in screening practices and respondents’ age but did find statistical significant

difference with marital status and levels of education. Married women were more likely to

have been screened at least once for cervical cancer than unmarried women as 81.6% of

65
the 49 respondents who screened for cervical cancer were married. Further, only those who

had tertiary education had ever screened for cervical cancer (100%). Of note, the odds of

having high knowledge were significant within groups based on their age group, marital

status and level of education. Participants who were single in both groups were more likely

than married participants, and those with tertiary education were more likely than the rest

of the groups to have high knowledge of cervical cancer and cervical cancer screening.

Similar to findings in another study that reported that the odds of screening for cervical

cancer was 5.8 times more in women who had never been married and 3.3 times in married

women (Mbachu, Dim, & Ezeoke, 2017).

Limitations

While the results of this study are very promising, there are some notable

limitations. The study was conducted in urban setting, included only participants who can

read and write in English, and most were college graduates. Further research is needed to

validate the effectiveness of the educational intervention with a different population,

setting, and with different socio-economic backgrounds. The use of a pre-post study design

and relatively small sample size make it necessary for further research on larger sample

using a rigorous research design. The use of immediate pre and posttest method limits the

generalization of the result as the result reflects only short-term cognitive responses. Also,

the participants were not followed up to ascertain their uptake of the preventive measures

and considering that some studies reported poor uptake even with increase awareness,

knowledge and willingness; it will be pertinent to investigate means to encourage uptake

when other factors are positive. The changes overtime were not evaluated, hence the need

for a longitudinal study. Further research should have multiple contacts with participants

66
and allow time for recollection of information and observe for uptake of the preventive

measures.

Another limitation is that while the content in both educational interventions was

the same, emphasizing certain aspects of the content was more easily accomplished in the

Presentation modality. For example, post-intervention knowledge of HPV infections being

asymptomatic appears notably more improved in the Presentation Group. That difference

might be attributed to the fact that the asymptomatic characteristic of HPV was repeatedly

emphasized in during the presentation whereas it is stated only once in the pamphlet. Thus,

the intervention strategies that were implemented could likely be further improved upon

and tailored to more effectively deliver the health promotion messages.

Conclusion

These findings of this study, which measured outcomes of a community-based

health education intervention using two educational strategies designed to increase

knowledge and behavioral intent related to HPV vaccination and cervical screening,

provides baseline evidence that low-cost interventions may increase awareness and

knowledge. It is inevitably value-laden that credible evidence is required to reduce the gap

between the health needs and resources available to respond to them. These findings

indicate that targeted health education (face-to-face presentation and printed pamphlet) are

effective approach for improving HPV, cervical cancer and preventive measure awareness

and knowledge, as well as improving intent to participate in HPV vaccination and

screening services. To be effective, HPV health education programs should incorporate the

knowledge, needs, interests, culture, values and beliefs of the target population and address

issues across all levels of prevention. This study was unique in offering both detailed HPV

67
infection, cervical cancer and the preventive measures information to men and women

living in urban settings. Earlier intervention studies in Nigeria have focused only on

women, cervical cancer and screening, but this is the first to include men and combine

HPV, cervical cancer and the preventive measures. We found that a large majority of men

and women are willing to take and or encourage HPV vaccination and cervical cancer

screening to their family and friends, if adequate information is provided to them,

consistent with the literatures cited earlier.

Considering the low research funding in developing nations, and the need to assess

people living in hard to reach areas, the evidence has implications for public health

planning and implementation. Relative to use of multiple educational strategies our finding

suggests that educational interventions, delivered via print material or face-to-face group

presentations may be low cost approaches that could be used by non-government and

government programs in low resource settings. Importantly, study results suggest that

group and individual educational strategies that deliver the same content may be effectively

used to reach sub-sets of the population.

Additionally, school-based vaccination may be another way to increase HPV

vaccination. The sexual nature of HPV infection and the psychosocial factors related to

STI, which may have profound effect on uptake vaccine and screening should be

considered when planning interventions to improve uptake. Finally, the inclusion and

participation of men in the study promotes the recommendation to mobilize and educate

men as partners rather than barriers in women’s health. Evidence-informed approaches of

including and working with men are needed to challenge several barriers influencing HPV

vaccination and screening uptake, since men play huge roles in sexual and reproductive

68
health in SSA countries. Overall, the study findings lay the groundwork for further

interventions to promote involvement of men in the reduction of HPV and cervical cancer

in Nigeria.

Recommendations

Our findings indicate that increasing public understanding of the virus, its

relationship with cervical cancer and the associated preventive measures are important

steps to improve uptake. The study improved awareness, knowledge, as well as intent to

take and/or encourage HPV vaccination and cervical cancer screening services. Replicating

the study to see if increased knowledge and intention will translate into actual uptake of

HPV vaccination and cervical cancer Screening. Due to our limited sample size,

widespread implementation of at least two educational strategies among different

geographic regions ethnic and religious populations across Nigeria would shed light on the

long-lasting impact of HPV and cervical cancer education. Future research should compare

HPV, cervical cancer and their preventive measures awareness, knowledge and intention

across sexes in Nigeria in order to identify if there are significant differences in awareness,

knowledge and intention. Additional investigations should be conducted among men or

community male leaders only to see if it will mitigate most of the negative psychosocial

barriers in Sub Sahara Africa. There is need for future longitudinal research to evaluate the

effect of various interventions on increasing HPV vaccination and cervical cancer

screening in Nigeria. Though this study was guided by two theories, future research is

needed to use theory to inform the development of interventions. Lastly, it is important to

develop evaluation and feedback tools to assess the effectiveness of the programs and to

69
be able to continuously improve the effectiveness of HPV vaccination and cervical cancer

screening interventions and programs.

70
 CHAPTER 4

ADDRESSING STIGMA AND IMPROVING HPV AND CERVICAL CANCER

KNOWLEDGE IN NIGERIA: ASSESSMENT OF A COMMUNITY-BASED

EDUCATIONAL INTERVENTION

71
Introduction

Human papillomavirus (HPV) is the most common viral infection of the

reproductive tract, and a highly prevalent group of viruses among sexually active men and

women worldwide (World Health Organization [WHO], 2018). HPV is mainly transmitted

through sexual contact, but skin-to-skin genital contact is a well-established mode of

transmission (WHO, 2018). The prevalence of HPV among the general population is

unknown in Nigeria, but there are reports of a seroprevalence rate of 43% among women

in the northern state of Birnin-Kebbi (Aminu et al., 2014). Others have reported HPV-IgG

antibodies in over a quarter of the general population in Southern Nigeria (Bruni et al.,

2014; Okolo et al., 2010). Of note, Aminu and colleagues (2014) reported that the HPV

infection was not significantly associated with women’s sexual behavior and found similar

seroprevalence rates among women in both monogamous and polygamous marriages

(Aminu et al., 2014). Furthermore, a link has been established between the HPV status of

men and the risk of cervical cancer in their sexual partners (Bosch et al., 2002; Castellsagué

et al., 2003). HPV is estimated to cause about 5% of human cancers (de Martel et al., 2012;

Bosch et al, 2013); and found to be associated with the development of anogenital cancers

(cervical, vaginal, vulvar, penile, and anal), oropharyngeal cancer, and genital warts (CDC,

2017).

Nigeria has one of the most extensive epidemics of cervical cancer in sub-Saharan

Africa (Ferlay et al., 2014; Oguntayo et al., 2011), with a high incidence and mortality

rates. Cervical cancer is the second most common female cancer in many parts of Nigeria

(Oguntayo et al., 2011), and results in annual death of approximately 14,000 women

(Ogundipe, 2013). Thus, on average, every hour one Nigerian woman dies of cervical

72
cancer (Ogundipe, 2013). The vast majority of cervical cancer cases are attributable to HPV

infection, which are preventable. A comprehensive approach that includes prevention (i.e.,

HPV vaccination), effective screening (i.e., Pap smear, Visual Inspection with Acetic Acid

[VIA] and HPV tests), early diagnosis, and treatment can significantly reduce the risks of

HPV infection and cervical cancer. However, in Nigeria the uptake of these preventive

approaches is low (Idowu, Olowookere, Fagbemi, & Ogunlaja, 2016; Wright et al., 2014).

Among the majority of the Nigerian population there are low levels of HPV infection and

cervical cancer knowledge (Ezenwa, Balogun, & Okafor, 2013; Ndikom & Ofi, 2012).

Other barriers to cervical cancer screening include lack of knowledge of the disease and

screening techniques, stigma and modesty, and lack of spousal support (Lim & Ojo, 2017).

This study was guided by the Theory of Gender and Power, which explores the

depths of sexual inequity, gender and power imbalance (Connell, 1987). This theory further

emphasizes social mechanisms that play an active role in maintaining in gender disparities

and inequities in women’s lives. These inequalities and barriers can be economic, physical,

social or personal in nature and operate at the interpersonal and individual levels. Each

social structure constitutes different risk factors and exposures that increase Nigerian

women’s vulnerability to HPV infection and cervical cancer. Spousal support in form of

male involvement is important in addressing these exposures and risk factors (Wingood &

DiClemente, 2000). Wingood and DiClemente (2000) applied Connell’s Theory of Gender

and Power in their examination of HIV-related exposures, risk factors, and interventions,

noting how gender-based inequities contribute to the generation of risk factors that

adversely affect women’s health. Among these are gender discrimination, exclusion,

labeling and stereotypes, which contribute to social stigma (Link & Phelan, 2001;

73
Trammell & Morris, 2012). The link between HPV, a sexually transmitted virus, and

cervical cancer could contribute to stigmatization of cervical cancer and possibly to

reluctance to receive HPV vaccine and cervical cancer screening. In their research with

Chinese women in Hong Kong, Lee and colleagues (2007) noted that it was a difficult for

their participants to accept the possibility that any sexual behavior could lead to HPV

infection and subsequently to cervical cancer. Among women who tested positive for HPV

during cervical screening, McCaffery and colleagues (2006) observed feelings of stigma

and shame only when the women were aware that HPV is transmitted through sexual

contact.

The stigma associated with sexually transmitted infections (STI) may create

barriers to information seeking, screening, and treatment (Fortenberry, 2004; Lim & Ojo,

2017). Of note, a higher level of knowledge has been associated with less expressed stigma,

especially in sexually transmitted infections like HIV (Exner et al., 2009). Furthermore,

support from spouses or male community members can be a key motivation for increasing

HPV vaccination and cervical cancer screening especially in male-dominated societies

(Kim et al., 2012; Lim & Ojo, 2017; Lyimo & Beran, 2012). Despite men’s key role in

reproductive and sexual health, HPV and cervical cancer programs in Nigeria have focused

only on women, and to date, no research has examined the stigma-associated with HPV

and cervical cancer. Interventions involving men and addressing stigma are urgently

needed to improve awareness, spousal support, and reduce HPV and cervical cancer stigma

in Nigeria. Therefore, one of the aims of this study was to examine the effectiveness of an

educational intervention in improving knowledge of, and reducing stigma associated with,

HPV and cervical cancer. A further aim was to identify and compare the differences

74
between men and women in Nigeria. The study was conducted in Anambra State. Anambra

State the second most densely populated state in Nigeria, with an estimated 2013

population of 5,366,900 (National Population Commission of Nigeria, 2015). A highly-

urbanized state, 62% of the population of Anambra is urban and literacy levels are high.

Method

The research aim was to evaluate the impact of an educational intervention on

knowledge and stigma among a sample of urban-dwelling Nigerian men and women. The

University of South Carolina Institutional Review Board reviewed and approved the

research protocols on 12/4/2017. Inclusion criteria were men and women aged 18 to 65

years who were able to read and write in English. Data collection spanned for four weeks

from December 2017 and January 2018. The primary investigator personally recruited

participants from 12 urban locations in Anambra, Nigeria (e.g., churches, businesses,

healthcare institutions) and verbally explained the study purpose, eligibility criteria,

confidentiality, and the voluntary nature of study participation to all potential participants.

Participants recruited from churches and other organizations received information about

the study from the priests, lay leaders, and organizational leaders. Nigeria is a country

where faith has a substantial role with 87% of people reporting religious service attendance

at least once a week, churches have been used effectively in health promotion interventions

(Ezeanolue, et al., 2015; Ucheaga, & Hartwig, 2010; Abanilla, et al., 2010).

Prior research has shown that increasing awareness and knowledge of HPV, HPV

vaccination, and cervical cancer, and cervical cancer screening has been effective in

increasing both behavioral intention and behavior, our aim was to implement an

educational intervention that could be efficiently delivered to groups in natural settings

75
such as churches or delivered to individuals who may not be accessible in group settings.

Based on the assumption that some members of the target population would be more

accessible and/or amenable to a group intervention and others to an individual intervention,

two different strategies for delivering the same health education content were employed to

maximize population reach. Participants were given the opportunity to choose between

attending an oral presentation or receiving printed materials.

A total of 281 participants who met the inclusion criteria were enrolled to receive

the intervention and almost 95% (n=266) completed the pretest, intervention and the post-

test. Only participants who completed the pre- and post-intervention surveys were included

in the final analysis. The timing of the group presentations was coordinated with, and

approved by, the officials at each site. Consistent with cultural norms in Nigeria, prior to

data collection, the researcher obtained verbal informed consent, rather than written

consent from all participants. Each study participant completed the self-administered paper

questionnaire supplied by the researcher. The survey instrument used had been previously

developed to assess the knowledge, attitude and practice of HPV and cervical cancer

preventive measures among Nigerian men (Nkwonta and Messias, 2018) and was

culturally modified to address gender issues within the context of Nigerian culture. The

original instrument was based on items from Cervical Cancer Free Coalition National

Surveys, Health Information National Trends Survey and previous studies on HPV and

cervical cancer among men in Ghana, Kenya and South Africa (Maree, Wright, & Makua,

2011; Rosser, Zakaras, Hamisi, & Huchko, 2014; Rwamugira, Maree, & Mafutha, 2017;

Williams, & Amoateng, 2012).

76
 Intervention strategies. The community-based intervention was delivered as

either a face-to-face health education presentation or a printed pamphlet, both containing

identical information on HPV infection, cervical cancer, HPV vaccine and cervical cancer

screenings. We developed the intervention content from the educational materials available

on the Center for Disease Control and Foundation for Women’s Cancer websites (CDC,

2017; Foundation for Women’s Cancer, 2017). We adopted and modified the presentation

of the materials to make them more culturally and environmentally appropriate for the

urban Nigerian population. Pre-intervention, all participants completed the demographic

information section and the self-administered questionnaire consisting of multiple-choice,

open and close-ended items. Subsequently participants either read the educational

pamphlet or listened to an oral presentation by the investigator, followed by completion of

the post-assessment survey.

The educational content covered the following topics: (a) pictorial and introductory

information on the HPV, including statistical facts of HPV incidence in Nigeria, (b)

pictorial and introductory information on the cervix and cervical cancer, including

statistical facts of cervical cancer incidence in Nigeria, (c) introduction of the HPV

vaccination as a protective and preventive method for HPV infection and cervical cancer,

(d) introduction of the cervical cancer screening as a preventive and early detection method

for cervical cancer, (e) information on common misconceptions, (f) availability of HPV

vaccination and cervical cancer screening in local pharmacies and hospitals, and (g) cost

of vaccines and screenings. At post-test, all participants completed the same instrument.

All sessions were personally conducted by the primary investigator.

77
 Measures and Analysis. The primary outcomes of interest were knowledge of

HPV, HPV vaccine, cervical cancer and cervical cancer screening, and stigma-associated

with HPV and cervical cancer. We also collected sociodemographic information (i.e., age,

marital status, education, and monthly income). Survey data were entered manually into

two excel sheets and cross-checked for correctness. Statistical analysis was conducted

using Statistical Analysis System (SAS) software version 9.4. Descriptive analysis (mean,

frequency and percentage) were used to calculate the socio-demographics and compare the

knowledge and stigma variables at pre-test and post-test. To assess for their level of

knowledge, a composite score was computed for each respondent by assigning a score of

0 to each wrong answer and 1 to each correct answer. Knowledge level was categorized as

follows: low, 0-4; fair, 5-9; high, 10-13. T-tests were used to assess for significant

differences in knowledge and stigma for both groups at pre-test and post-test. Logistic

regression analysis was used to calculate the factors associated with knowledge and stigma

associated with HPV and cervical cancer. Statistical significance was set at a p-value of

<0.05.

Results

Only participants who took the pre- and post-test were included in the analysis. Of

the 266 participants, 114 were men and 147 were women. There are differences in number

of responses by topic because participants who have never heard of HPV and or cervical

cancer were told to skip other HPV and cervical cancer knowledge questions. The sample

of participants (Table 4.1) included nearly equal proportions of men and women with a

mean age of 37.8 +11.1 for men and 36.1 +9.43 for women. The dominant age groups

were individuals between 24-34 and 35-44 years. The majority of the participants were

78
married and had tertiary education. There were no statistically significant differences

between men and women in regard to participants’ age, age group, marital status or

educational level. The participants’ monthly income differed significantly by gender, with

more than half the women (56.9%) earning less than 50, 000 Nigerian Naira every month.

Table 4.1: Summary of participants’ characteristics

Characteristic Men n(%) Women n(%) T test
Age, years (mean+SD) 37.8 +11.1 36.1 +9.43 0.2032
Age group (years)
18 -24 4 (3.51) 4 (2.72)
25 - 34 47 (41.2) 67 (45.6) 0.3065
35 - 44 34 (29.8) 46 (31.3)
45 - 54 18 (15.8) 23 (15.7)
55 and above 11 (9.65) 7 (4.76)
Marital status
Single 46 (40.4) 49 (32.5) 0.1887
Married 68 (59.7) 102 (67.5)
Educational level
No formal education 1 (0.88)
Primary education 3 (2.63) 1 (0.67) 0.5222
Secondary education 23 (20.2) 34 (22.7)
Tertiary education 87 (76.3) 115 (76.7)
Monthly income
Less than #50, 000 39 (36.1) 83 (56.9) 0.0005
#50-100,000 31 (28.7) 35 (24.0)
Above #100,000 38 (35.2) 28 (19.2)

Awareness and Knowledge of HPV, Cervical Cancer and the Screening

Measures. Table 4.2 presents data related to participant awareness and knowledge of HPV

and cervical cancer. At baseline, the majority of the men (62.6%) and women (70.2%) had

never heard of HPV; which was reduced to less than 4% at post-intervention; there was no

statistical difference between the two groups (p=0.2659). Similarly, at baseline few

participants (30.2% of men and 25.8% of women) knew that HPV is sexually transmitted,

but at post-intervention, the clear majority of men (95%) and women (94%) had attained

79
this knowledge (p <0.05). In terms of knowledge regarding susceptibility to contracting

HPV, there was a significant difference observed between baseline (p >0.05) and post

intervention (p <0.05) responses. Pre-intervention awareness of HPV vaccine was very low

and differed between the two groups (p=0.0055), with 72.6% of men and 84.8% of women

not aware of HPV vaccine. Post-intervention, lack of awareness was less than 10% in both

groups. Furthermore, knowledge of the appropriate age group for HPV vaccine went from

less than 14% at pre-test to 60% at post-intervention in both groups, with no statistically

significant difference between groups (0.9653).

Table 4.3 presents the data related to pre- and post-intervention cervical cancer

awareness and knowledge. There were significant increases in all the measures of cervical

cancer awareness and knowledge. In contract to the awareness and knowledge of HPV and

HPV vaccine, a majority of the participants were aware of cervical cancer. At baseline,

more than 72% and 62% of men and women were aware of cervical cancer, but less than

58% knew that having multiple sexual partners increase the risk of getting cervical cancer.

At baseline there were statistically significant differences in level of awareness of the risk

factors for cervical cancer (0.0043), awareness of cervical cancer being caused by an

infection (0.0073), and awareness of HPV infection as the major cause of cervical cancer

(0.0005) but no statistical differences at post intervention (p>0.05 for all). Although the

majority of the participants were aware of cervical cancer at baseline, very few (20.2% of

men and 24.5% of women) were aware of any type of cervical cancer screenings. After the

targeted educational intervention, awareness of cervical cancer screening increased to

76.5% in men and 80.8% in women (0.0245).

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Table 4.2: Participants Knowledge of HPV and HPV Vaccine
Variables Pre-Intervention n(%) Post-Intervention n(%)
Men Women p Men Women P
Have you ever heard
of HPV? No 72(62.6) 106(70.2 4(3.38) 5(3.31)
Yes 31(27.0) 26(17.2) 0.5255 110(95.7) 140(92.7) 0.2659
Not sure 12(10.4) 19(12.6) 1(0.87) 6(3.97)
How do you think one
can get HPV?
Physical contact 7(6.09) 1(0.66) 0.0217 14(12.4) 9(5.96) 0.0809
Dirty toilets 7(6.09) 7(4.64) 0.6075 2(1.74) 15(9.93) 0.0030
Poor personalhygiene 8(6.96) 12(7.95) 0.7607 8(6.96) 13(8.61) 0.6175
Sexual intercourse 35(30.2) 39(25.8) 0.4114 110(95.7) 142(94.0) 0.5535
How do you know
when someone has
HPV? Itching 20(17.4) 8(5.30) 0.0028 12(10.4) 23(15.2) 0.2430
Pain during urination 7(6.09) 6(3.97) 0.4429 13(11.3) 17(11.3) 0.9907
Genital discharges 13(11.3) 16(10.6) 0.8556 31(27.0) 56(37.1) 0.0783
Genital rash 20(17.4) 8(5.30) 0.0028 16(13.9) 16(10.6) 0.4195
No symptoms 10(8.70) 13(8.61) 0.9803 65(56.5) 71(47.0) 0.1253
Who can contract
HPV? Male only 9(9.38) 0 2(1.80) 0
Female only 11(11.5) 9(9.38) 0.0056 12(10.8) 7(4.79) 0.0233
Male and female 32(33.3) 35(36.5) 97(87.4) 139(95.2)
What factors increase
the risk of getting
HPV? Poor diet 6(5.22) 0(0) 0.0137 2(1.74) 5(3.31) 0.4103
Smoking 4(3.48) 14(9.27) 0.0487 37(32.2) 52(34.4) 0.6991
Poor personalhygiene 12(10.4) 7(4.64) 0.0840 14(12.3) 16(10.6) 0.6726
Many sexual partners 32(27.8) 40(26.5) 0.8094 102(89.5) 137(90.7) 0.7371
Tick the disease you
think HPV can cause?
Cancer of Anus 7(6.09) 7(4.64) 0.6075 65(56.5) 69(45.7) 0.0807
Cancer of cervix 27(23.5) 33(21.9) 0.7555 89(77.39) 124(82.1) 0.3467
Genital warts 14(12.1) 10(6.62) 0.1324 30(26.6) 39(25.8) 0.8957
Cancer of Penis 4(3.51) 9(5.96) 0.3456 69(60.5) 72(47.7) 0.0377
Cancerofmouth/throat 9(7.83) 11(7.28) 0.8695 56(48.7) 66(43.7) 0.4212
Cancer of Vagina 12(10.4) 12(7.95) 0.4922 63(54.8) 91(60.5) 0.3728
Have you heard about
HPV vaccine? No 82(72.6) 128(84.8 12(10.4) 13(8.72)
Yes 20(17.7) 20(13.3) 0.0055 98(85.2) 133(89.3) 0.8879
Not sure 11(9.73) 3(1.99) 5(4.35) 3(2.01)
Who can take the
vaccine?
Boys & girls 8(6.96) 21(13.9) 0.0611 69(60.0) 91(60.3) 0.9653
Young men & women 19(17.0) 26(17.2) 0.9570 77(67.0) 92(60.9) 0.3110

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Table 4.3. Knowledge of Cervical Cancer and Cervical Cancer Screening
Variables Pre-Intervention n(%) Post-Intervention n(%)
Men Women p Men Women P
Have you ever heard
of cervical cancer?
No 24(21.1) 35(23.2) 3(2.65) 2(1.34)
Yes 83(72.8) 95(62.9) 0.4076 106(93.8 138(92.6 0.2374
Not sure 7(6.14) 21(13.9) 4(3.54) 9(6.04)
Which of the following
do you think increases
the risk of getting
cervical cancer?
Smoking 26(22.6) 40(26.5) 0.4665 42(36.5) 71(47.0) 0.0854
Multiple sexual 46(40.0) 87(57.6) 0.0043 94(81.7) 134(88.7 0.1166
partners
Do you think cervical
cancer is associated
with an infection? No 4(43.7) 38(27.0) 0.0073 7(6.36) 10(6.67) 0.9223
Yes 58(56.3) 103(73.0 103(93.6 140(93.3
If yes; what type of
infection is cervical
cancer associated
with?
HPV infection 30(26.1) 69(46.6) 0.0005 96(83.5) 136(90. 0.2614
Cervical cancer be
prevented? No 17(16.0) 15(10.3) 0.1961 4(3.60) 5(3.38) 0.9227
Yes 89(84.0) 130(89. 107(96.4 143(96.6
Early detection of
cervical cancer is
helpful? No 8(7.55) 12(8.11) 3(2.73) 4(2.78)
Yes 98(92.5) 136(91.9 0.8700 107(97. 140(97.2 0.9806
Have you heard about
Pap smear test or
Visual Inspection with
Acetic Acid (VIA)?
No 74(64.9) 94(62.3) 11(9.57) 21(13.9)
Yes 23(20.2) 37(24.5) 0.9132 88(76.5) 122(80.8 0.0245
Not sure 17(14.9) 20(13.3) 16(13.9) 8(5.30)
Have you heard about
HPV test? No 68(60.2) 106(70.2 7(6.14) 14(9.40)
Yes 24(21.2) 32(21.2) 0.0284 100(87.7 126(84.6 0.4670
Not sure 21(18.6) 13(8.61) 7(6.14) 9(6.04)
Who can take Pap
smear test or VIA or
HPV test? Women 33(29.0) 64(42.4) 0.0229 94(81.7) 135(89. 0.0833

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 Level of Knowledge of HPV, and Cervical Cancer. Table 4.4 presents data on

the level of HPV and cervical cancer knowledge. Overall, prior to the educational

intervention, respondents’ level of knowledge of HPV, and cervical cancer were low, but

improved at post-test. The majority of participants (81.7% of men and 84.7% of women)

had poor knowledge of HPV and HPV vaccine at baseline. Following the intervention,

participants’ knowledge significantly improved, with poor knowledge persisting among

less than 13%, while nearly 50% had high HPV-related knowledge. At pre-intervention,

the level of cervical cancer knowledge among men and women was significantly different

(0.0012), with no significant differences at post-intervention.

Table 4.4: Participants’ Level of Knowledge of HPV, HPV Vaccine, Cervical Cancer and
Cervical Cancer Screening Pre-Intervention and Post-Intervention
Variables Pre-Intervention n (%) Post-Intervention n (%)
Men Women p Men Women p
Level of Knowledge
of HPV and HPV
Vaccine.
Poor 94(81.7) 127(84.7) 0.9677 14(12.2) 19(12.6) 0.5916
Moderate 17(14.8) 13(8.67) 39(33.9) 57(37.8)
High 4(3.48) 10(6.67) 62(53.9) 75(49.7)
Level of Knowledge
of Cervical Cancer
and Cervical Cancer
screening?
Poor 46(40.0) 39(25.8) 11(9.57) 4(2.65) 0.0702
Moderate 40(34.8) 46(30.5) 0.0012 19(16.5) 26(17.2)
High 29(25.2) 66(43.7) 85(73.9) 121(80.1)

Stigma Associated with HPV Infection and Cervical Cancer. In terms of stigma

(see Table 4.5), no significant changes were observed pre/posttest in five out of the six

domains; however, there were no statistically sig differences except for “Do you believe

telling someone you have (had) cervical cancer is risky”. Some participants moved from

uncertainty (i.e., “not being sure”) at pre-test to blaming or stigmatizing victims at post-

83
test. For example, at pre-test, 11.5% of men and 16.6% of women indicated testing positive

to HPV infection was associated with having multiple sex partners. However, at post-test,

33.9% of men and 32.5% of women agreed that a positive HPV test result did mean the

person had multiple sex partners. Similar response trends were noted in relation to the

perception of individuals with cervical cancer as having had multiple sexual partners.

Of note, gendered perceptions of disclosure of having cervical cancer were not very

different before the intervention but became statistically significant (0.0394) after the

intervention. At pre-test, 20.2% of men and 35.1% of women agreed disclosing ones’ status

is risky, whereas following the educational intervention, 31.3% of men and 43.1% of

women agreed that it is risky for an individual to disclose their status.

Factors associated with high knowledge of HPV and cervical cancer. The

results of logistic regression analyses on knowledge of HPV and HPV vaccine at post

intervention (Table 4.6). The odds of high knowledge of HPV and HPV vaccine is 3.4

times for male participants (ages 45-54) than the odds of high knowledge of HPV and HPV

vaccine for participants who are 55 years and above. The adjusted odds of having high

knowledge of HPV and HPV vaccine is 1.7 times for male single participants and 2.4 times

for those who earn more than 100,000 naira than the odds of married participants and those

who earned less than 50,000 naira respectively. These categories were found to be

statistically different. However, no statistically significant differences were observed based

on their age group, marital status, education and income for the women.

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Table 4.5. Stigma Associated with HPV Infection and Cervical Cancer
Variables Pre-Intervention n(%) Post-Intervention n(%)
Men Women p Men Women p
Do you think people
with HPV infection
sleep with a lot of
different people?
No 22(19.5) 34(22.5) 35(30.4) 43(28.5)
Yes 13(11.5) 25(16.6) 0.2729 39(33.9) 49(32.5) 0.5948
Not sure 78(69.0) 92(60.9) 41(35.7) 59(39.0)
Do you think people
with cervical cancer
sleep with a lot of
different people?
No 30(26.5) 46(30.5) 43(37.4) 47(31.1)
Yes 15(26.5) 16(10.6) 0.6407 33(28.7) 40(26.5) 0.1624
Not sure 68(60.2) 89(58.9) 39(33.9) 64(42.4)
Do you think people
who have (had)
cervical cancer caused
their problem?
No 43(37.7) 67(44.4) 52(45.2) 58(38.4)
Yes 7(6.14) 20(13.3) 0.0835 26(22.6) 41(27.2) 0.3982
Not sure 64(56.1) 64(42.4) 37(32.20 52(34.4)
Do you think that a
person affected by
cervical cancer is
disgusting?
No 59(51.8) 66(43.7) 74(64.4) 87(57.6)
Yes 10(8.77) 28(18.5) 0.5848 10(8.70) 23(15.2) 0.5245
Not sure 45(39.5) 57(37.8) 31(27.0) 41(27.1)
Do you feel
uncomfortable around
someone affected by
cervical cancer?
No 48(42.1) 67(25.3) 62(54.4) 80(53.0)
Yes 17(14.9) 37(14.0) 0.2068 20(17.5) 30(20.0) 0.9639
Not sure 49(43.0) 47(31.1) 32(28.1) 41(27.2)
Do you believe telling
someone you have
(had) cervical cancer is
risky?
No 51(44.7) 53(35.1) 54(47.0) 47(31.1)
Yes 23(20.2) 53(35.1) 0.6826 36(31.3) 65(43.1) 0.0394
Not sure 40(35.1) 45(29.8) 25(21.7) 39(25.8)

85
Table 4.6: Regression Analysis of Factors Associated with High Knowledge of HPV and
HPV Vaccination at Post Intervention
Men Women
Odds 95% CI for OR Odds 95% CI for OR
Ratio Lower Upper ratio Lower Upper
Age group
18 - 24 0.3739 0.05972 2.3408 3.1758 0.3236 31.1711
25 - 34 0.8051 0.4656 1.3921 0.7361 0.4640 1.1678
35 - 44 1.6675 0.8422 3.3017 1.0653 0.6087 1.8645
45 - 54 3.4232 1.1402 10.2775 1.7584 0.7613 4.0614
55+ (referent)
Marital status
Single 1.7276 1.0622 2.8098 1.1548 0.7892 1.6898
Married (referent)
Education Level
No formal education 1292187 0 Infty
Primary education 0.1805 0.02102 1.5507 1.632E-7 0 Infty
Secondary education 0.6113 0.9522 1.3259 0.9694 0.5081 1.8498
Tertiary education
(referent)

Monthly income
(Nigerian Naira)
Less ₦50,000 (referent)
₦50-100,000 0.8099 0.4135 1.5865 1.0108 0.5334 1.9154
Above ₦100,00 2.4497 1.2222 4.9099 1.7922 0.8367 3.8388

Regarding knowledge of cervical cancer and cervical cancer screening at post

intervention (Table 4.7), for participants aged 35-44, the odds of high knowledge

of cervical cancer and cervical cancer screening is 3.6 times for men and 8.1 times for

women than the odd of high knowledge for men and women who were 55 years and above.

Additionally, men had 1.9 times and women had 3.5 times the odds of high knowledge

of cervical cancer and cervical cancer screening than the participants aged 55 years and

above. In terms of marital status, a significant difference was observed. The odds of high

knowledge of cervical cancer and cervical cancer screening for single male participants

86
were 2.1 times and 4 times for single female participants than the odds for married

participants.

Table 4.7: Logistic Regression Estimates (Odds Ratio) of High Knowledge of Cervical
Cancer at Post Intervention.
Men Women
Odds 95% CI for OR Odds 95% CI for OR
Ratio Lower Upper ratio Lower Upper
Age group
18 - 24 0.4189 0.06733 2.6069 3.2182 0.3258 31.7851
25 - 34 1.9317 1.0640 3.5068 3.5477 1.9945 6.3105
35 - 44 3.6420 1.6136 8.2204 8.1928 3.2415 20.7074
45 - 54 1.7506 0.5236 5.8533 6.8627 2.0162 23.3600
55+ (referent)
Marital status
Single 2.1985 1.1863 4.0745 4.0408 2.0076 8.1331
Married (referent)
Education Level
No formal education 2245761 0 Infty
Primary education 0.2192 0.02544 1.8882 0.4258 0.01135 15.9670
Secondary education 1.1797 0.5326 2.6130 2.4383 1.1708 5.0780
Tertiary education (referent)

Monthly income (Nigerian

Naira)
Less ₦50,000 (referent)
₦50-100,000 2.1751 1.0283 4.6005 6.0326 2.3406 15.5482
Above ₦100,00 4.3848 1.9412 9.9047 6.2316 2.1353 18.1865

Discussion

To the best of our knowledge, this study is the first in Nigeria to compare the

efficacy of an educational intervention in improving levels of awareness and knowledge

of HPV, HPV vaccine, cervical cancer and cervical cancer screening among men and

women and to examine the effect of an educational intervention on stigma associated

with HPV and cervical cancer. These findings indicate that community-based health

education, whether delivered to groups or to individuals, is a promising strategy to

increase HPV and cervical cancer awareness and knowledge among urban-dwelling

87
Nigerian men and women. Similar to prior research conducted in other regions of Nigeria

and other countries in sub-Saharan Africa, at pre-intervention we observed low levels of

awareness and knowledge of HPV, cervical cancer and preventive measures (Gana et al.,

2016; Odunyemi, Ndikom, & Oluwatosin, 2018; Rwamugira, Maree, & Mafutha, 2017;

Williams & Amoateng, 2012). A study in Singapore found that only 16% of the sample

of men had ever heard of the HPV (Pitts, et al., 2009). Increased awareness and

knowledge of HPV infection is vital for both men and women, given the significant health

complications of HPV infection in both groups.

Of note, post-intervention awareness and knowledge improved remarkably among

both men and women, with more than 80% correctly answering specific questions about

the risk factors, mode of transmission, and the preventive methods at post-test. Similarly,

Adamu et al., (2012) examined the impact of health information on knowledge of cervical

cancer in North-Western Nigeria and reported a significant difference (p<0.001) in

knowledge with a mean score 63.7% among female teachers who participated in the

intervention. Following a nurse-led educational intervention in Abuja, Nigeria, Odunyemi

and colleagues (2018) reported a significant increase (mean score 9.6 ± 7.2 to 21.5 ± 6.2)

in cervical cancer and HPV knowledge. Prior to the educational intervention, 83.4% of the

participants had poor knowledge of HPV and HPV Vaccine, compared to 12.4% following

the intervention, and those with good knowledge increased from 5.28% to 51.5%

(p <.0001). Among participants with poor knowledge of cervical cancer and cervical

screening, the proportion reduced from 32% to 5.64%, whereas those with very good

knowledge increased from 35.7% to 77.4% (p < 0.0001).

88
 Community members’ knowledge of the association of HPV as a STI sexually

transmitted infection may impede cervical cancer prevention efforts. The stigma associated

with STIs is increasingly recognized as a critical psychosocial element that may affect

uptake of preventive measures. A study among men in Ghana, found that the most common

belief was that cervical cancer is caused by frequent sex resulting in physical damage

(Williams & Amoateng, 2012). Of note, the proportion of participants in this community-

based research who associated testing positive for HPV infection with having had multiple

sex partners increased significantly after the intervention in both groups, as did the

perception of women diagnosed with cervical cancer. This is similar to the finding by

Fernandez, et al., (2009), who noted men reported they would suspect infidelity by their

partner, if their partner told them she was HPV positive. They also noted that even with

increased understanding that men’s own infidelity could be the cause of their partner's

infection, most men still stated that their first reaction would be to question the woman's

faithfulness.

Of further note is the post-intervention increase of men and women who indicated

individuals with cervical cancer had caused their own problem increased after the

intervention. These findings are consistent with previous research linking awareness of

HPV as sexually transmitted with significantly higher levels of stigma and shame

(McCaffery et al., 2006; Waller, et al., 2007). Similarly, research by Shepherd and Gerend

(2014) reported participants rated a patient with cervical cancer as more dirty, dishonest

and unwise when the cause of the cancer was specified than when it was not specified. The

findings from this research suggest the risk that raising awareness of HPV as a sexually

transmitted infection may potentially increase feelings of stigma and shame among those

89
infected. The increased stigma observed in this study indicate that most of the participants

are in Stage 2, unengaged, and stage 3, decision making time, of the Precaution Adoption

Process Model. This means there are significant gaps in their knowledge about HPV and

cervical cancer, including risk and protective factors. Specifically, continuing

dissemination of appropriate, culturally tailored and scientifically sound information

among diverse groups could contribute to the reduction of stigma associated with HPV and

cervical cancer, which over time could contribute to better health outcomes.

Stigma associated with lack of information is a common barrier to disclosure,

particularly in relation to information with sexual connotations. An individual’s ability and

willingness to disclose their status is dependent on the societal perception and feeling

toward HPV and cervical cancer. Following the educational intervention, respondents’

perceptions regarding the risk of disclosing to others that they have cervical cancer

increased in both groups, with more women not being willing to disclose their status. Our

finding revealed a statistically significant difference by gender in some of the key questions

such as who can contract HPV and knowledge of HPV vaccine and cervical cancer at both

preintervention and postintervention. More women than men had more stigmatized belief

about disclosing of status. In contrast, Perrin and colleagues (2006) reported that the

majority (65%) of the women in their study had disclosed their HPV diagnosis to at least

one other person. The finding may be due to internalized stigma associated with social

expectation of women in Nigeria and the patriarchal culture of the society. A permanent

change in awareness, knowledge and stigma associated with HPV and cervical cancer may

be achieved by adequate and sustained health education programs with or without other

interventions. Several strategies for stigma reduction tailored at intrapersonal,

90
interpersonal, community and organizational/institutional level are reported in the

literature (Heijnders, & Van Der Meij, 2006; Stangl et al., 2013). These strategies include

counselling, cognitive behavioral therapy, self-help, advocacy and support groups (Stangl

et al., 2013).

Conclusion

Awareness, knowledge, perceptions, and attitudes contribute to women’s exposure

to and susceptibility to HPV infection, and subsequently, to cervical cancer. In Nigeria,

given the high prevalence of HPV infection, there is an associated high prevalence of

cervical cancer. An increase in HPV and cervical cancer morbidity and mortality have

contributed to the urgent need to scale up HPV vaccine and cervical screening efforts. This

research assessed the effectiveness of a community-based educational interventions in

improving HPV awareness and knowledge among urban-dwelling Nigerian men and

women. The untoward finding of increased stigma associated with HPV and cervical

cancer following the educational intervention is not surprising, given that HPV is a sexually

transmitted virus, and as such may be associated with stigma. Given that stigma is a

possible hindrance to the uptake of HPV vaccine and screening, there is an urgent need for

implementing culturally tailored stigma reduction interventions at intrapersonal,

interpersonal, community and organizational/institutional to combat stigma associated

with HPV and cervical cancer. To reduce the negative connotations associated with the

HPV virus using health education, public information should focus on the cause of the

condition, asymptomatic nature of HPV infection, its widespread prevalence, and the fact

that most sexually active people will contract HPV at some point in their lives.

91
Limitations

There are several limitations to the methods and implications of this research. We

used a self-administered survey to assess the impact of this tailored, community-based

educational intervention and therefore were not able to identify any causal relationships

between knowledge, attitudes, or practices overtime. Furthermore, the nature of the

convenience sampling and urban setting limits generalizability to the larger Nigerian adult

population. Of note, the majority of the participants were college educated, which is not

representative of the general Nigerian population. Given the research included only

participants who can read and write in English, the sample also does not reflect non-English

speaking Nigerians.

Recommendations for further research

Educational interventions are effective at improving awareness, knowledge and

willingness to participate in preventive and screening services among diverse populations.

However, educational interventions do not necessarily remove or ameliorate structural

barriers to uptake of preventive and screening services. There is a need for further

exploration of the effectiveness of targeted educational interventions in improving HPV

and cervical cancer-related stigma in different circumstances, contexts and settings in SSA.

Further research is warranted to explore and uncover stigma and other emotional factors

that may influence HPV vaccination and screening utilization. It is important to assess HPV

knowledge and attitudes among diverse groups of Nigerian women, men, healthcare

providers and community leaders. To examine sources of stigma and develop culturally-

tailored strategies to combat the stigma, further research with larger samples of married

men, unmarried men in heterosexual relationship(s) and male community leaders is

92
warranted. There is also a need for further research to identify other educational

interventions and approaches to increase male involvement in HPV and cervical cancer

prevention, not only in Nigeria, but in other countries and cultures.

93
 CHAPTER 5
CONCLUSION AND RECOMMENDATIONS

94
Conclusion

The findings from this study support that health education is an effective tool for

increasing awareness, enhancing knowledge and encouraging willingness to engage in

HPV vaccination and screening services among Nigerian adults. Among the 266 urban-

dwelling Nigerian adults who participated in the study, the majority had low levels of

knowledge of HPV and HPV Vaccine at baseline. However, after exposure to the

community-based educational intervention, knowledge levels clearly increased. Of note,

very few of the 266 participants reported having received the HPV vaccine or having a

family member who had been vaccinated or screened for HPV. Following exposure to the

community-based, culturally tailored educational intervention, there was a clear increase

in reported intent to be vaccinated take and to encourage a family member to receive HPV

vaccination and cervical cancer screening. Of note are the findings related to negativity in

relation to HPV and cervical cancer stigma. We observed negative perception about HPV

and cervical cancer increased with increased knowledge of HPV and cervical cancer. This

may be due to increased awareness on sexual nature of HPV infection, as sexually

transmitted virus has a relationship with stigma. Therefore, increased continuing and

sustained public education on the asymptomatic nature of HPV, its prevalence and that

most sexually active people will contract HPV at some point in their life may help reduce

the negative feeling associated with the virus.

Unique aspects of this research were the inclusion of information on HPV

infection, cervical cancer and the preventive measures to both men and women in urban

settings. Earlier intervention studies in Nigeria have focused solely on women and cervical

cancer and screening (Adamu, Abiola, & Ibrahim, 2012; Abiodun, Olu-Abiodun, Sotunsa,

& Oluwole, 2014; Chigbu, Onyebuchi, Onyeka, Odugu, & Dim, 2017; Gana, Oche, Ango,

95
Raji, & Okafoagu, 2016; Mbachu, Dim, & Ezeoke, 2017; Wright, Kuyinu, & Faduyile,

2010; Ndikom et al, 2017; Ndikom, Ofi, Omokhodion & Adedokun, 2017; Odunyemi,

Ndikom, & Oluwatosin, 2018). This research is the first to include men and have a

combined focus on HPV infection, cervical cancer and specific preventive measures (i.e.,

HPV vaccination). Incorporating educational initiatives into community-based, non-

governmental and government-sponsored programs will lead to both increased awareness

and uptake of preventive measures. Other strategies to increase HPV vaccination include

school-based and workplace vaccination opportunities. Possible deterrents to HPV

immunization uptake include the sexual nature of HPV infection and the psychosocial

factors related to sexually transmitted diseases. Health educators and healthcare

professionals must consider these cultural and social factors in planning interventions to

improve HPV immunization uptake.

Of particular note was the importance of men’s participation in this research. This

study serves as an example of the importance of mobilizing and educating men as partners

rather than barriers in relation to women’s health issues. Given men’s roles and influence

in sexual and reproductive health access in SSA, further evidence-informed approaches

that include men as active participants and partners are needed to challenge the multiple

social, economic, and cultural barriers to HPV vaccination and screening uptake. The

findings of this study lay the groundwork for further research-based interventions to

promote involvement of men in the reduction of HPV and cervical cancer in Nigeria. This

study utilized the Theory of Gender and Power, applied to the men and women living in

Anambra. Caution should be taken when generalizing the results to other Nigerians. More

96
research is needed to identify the most effective theory-based interventions for evidence-

based nursing practice in this population.

Implications for Nursing Practice

Given that nurses are in a position to effect change and to promote healthy

preventive practices, the study findings are relevant to nursing practice, research and

policy. The positive impact of this targeted educational intervention in improving

awareness, knowledge and intention to take HPV vaccine and cervical cancer screening

among urban Nigerian men suggests that similar initiatives should be developed for other

populations and settings. However, nurses and nurse researchers also need to pay attention

to the gaps in the HPV knowledge, lack of uptake of preventative practices, and stigma

regarding HPV and cervical cancer, in order to develop and implement culturally focused

and tailored interventions to improve HPV vaccine and cervical cancer screening among

diverse populations and settings in Nigeria. Nurses need to be aware of the clinical

implications for population and be prepared to inform and educate both men and women

in Nigeria.

At the individual level, these findings may help inform nursing interventions with

female patients who lack the ability to make health decisions and influence decision

making by involving their significant others. Also, discussing the patient’s beliefs related

to HPV and cervical cancer and perceptions of vulnerability may contribute to reducing the

social stigma related to these diseases. Nurses can facilitate HPV vaccination and screening

uptake by participating in community health events and providing home visits.

Recommending and communicating accurate information to patients is an important role

for nurses. With ongoing rural to urban and international migration, it is important to

97
incorporate knowledge of new cultures and languages into nursing curriculums, at both the

baccalaureate and graduate levels, and to expose practicing nurses to various cultures and

sociocultural factors influencing health and illness. More research on HPV and cervical

cancer screening and the application of the Theory of Gender and Power among the

Nigerian population is needed. The current study provided information about the

applicability of the Precaution Adoption Process Model and the Theory of Gender anPower

in knowledge and intention to take HPV vaccination and cervical cancer screening in

Nigeria. Nurses who can access different tribes and region in Nigeria could incorporate

these theories into intervention strategies aimed at increasing the uptake of HPV vaccine

and cervical screening.

Recommendations

Based on the findings of this research, an effective community-based education

program for Nigerian urban-dwelling adults should incorporate information that reflects

the target population’s needs, interests, culture, values and belief. It should also integrate

activities and recommendations related to primary, secondary, and tertiary levels of

prevention. This targeted, culturally-tailored community-based educational intervention

improved awareness, knowledge, and intent to take and or encourage HPV vaccination and

cervical cancer screening services. The findings indicate that both enhancing public

understanding of HPV and the relationship of the virus and cervical cancer and increasing

uptake of effective preventive measures are important steps.

There are several opportunities for future research pertaining to methodology,

content area, and refinement of the conceptual framework. More evidence is required to

further explore the effectiveness of educational interventions in improving HPV and

98
cervical cancer-related stigma in different circumstances, contexts and settings in SSA.

Similar research should be conducted with larger and more diverse populations in both

urban and rural areas of Nigeria and further investigators are warranted to assess if

increased knowledge and intention actually translates into increased uptake of HPV

vaccination and other preventive measures.

Due to the geographically limited sample, more widespread implementation among

different geographic regions ethnic and religious populations across Nigeria is warranted

in order to would shed light on the long-lasting impact of HPV and cervical cancer

education. Examples of areas for further investigation include the comparison of HPV

knowledge, attitudes, and intent among more diverse samples of Nigerian men and women.

Further research clearly is warranted in the area of stigma and other emotional factors that

may influence decisions not to participate in HPV vaccination and screening. The roles and

influence of men, particularly male community leaders, also need to be investigated in

order to assess their roles in mitigating psychosocial barriers to HPV vaccination and

screening in diverse areas of SSA.

Further research is necessary to identify other tailored educational interventions to

encourage male participation and inclusion in HPV and cervical cancer prevention has

shown that information without removing the some of the social barriers may not yield the

desired effects. There is a need to review and assess the various interventions used to

increased HPV and cervical cancer knowledge and uptake in Nigeria in order to determine

their reach and effectiveness. Lastly, it is important to develop culturally appropriate

evaluation and feedback tools to assess the effectiveness of the programs and help create

an intervention that is more effective in promoting HPV vaccination and cervical cancer

99
screenings. An understanding of the applicability of the Theory of Gender and Power to

HPV vaccination and cervical cancer screening among in different cultural backgrounds is

needed before planning Theory of Gender and Power interventions.

100
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of Cancer Prevention, 11(1), 137-140.

Wright, K., Aiyedehin, O., Akinyinka, M., & Ilozumba, O. (2014). Cervical cancer:

community perception and preventive practices in an urban neighborhood of Lagos

(Nigeria). ISRN preventive medicine, 2014.

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Zamawe, C., Banda, M., & Dube, A. (2015). The effect of mass media campaign on Men’s

participation in maternal health: a cross-sectional study in Malawi. Reproductive

Health, Vol.12 No. 1, pp. 31.

Zhang, Y. Z., Ma, J. F., Zhao, F. H., Xiang, X. E., Ma, Z. H., Shi, Y. T., ... & Qiao, Y. L.

(2010). Three-year follow-up results of visual inspection with acetic acid/Lugol's

iodine (VIA/VILI) used as an alternative screening method for cervical cancer in

rural areas. Chinese journal of cancer, 29(1), 4-8.

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 APPENDIX A
INFORMED CONSENT FORM
Introduction and Purpose
I am Chigozie Nkwonta, a third year PhD student in the College of Nursing at the
University of South Carolina, USA. You are invited to take part in my study, which is my
dissertation. Before you decide whether or not to take part, it is important for you to
understand why the research is being done and what it will involve. Please take time to
read the following information carefully.

I am conducting an educational intervention to increase HPV and cervical cancer

knowledge and intention to screen for and take HPV vaccine. I want to assess what is
known about HPV and cervical cancer, and if provision of information will increase its
knowledge and intention to take HPV vaccine and cervical cancer screening. You have
been purposively chosen to participate in the study because you live in Anambra state and
is within the age or may have a dependent that is within the age for HPV vaccine and
cervical cancer screening. If you do decide to take part, the rest of this paper contains
information on what to expect. Please read it carefully. I am happy to answer any question
you have about this study before you decide to participate.
Description of Study Procedures
If you choose to participate, the researcher will explain the purpose of the study and a step-
by-step procedure for this study. Please, at the end of the information section with the
researcher, feel very free to ask any questions you may have. Then, you will be asked to
give consent. You can give verbal or written consent, depending on what you feel most
comfortable to do.

If you are deemed eligible, you will be enrolled in the study. Once enrolled, you will
complete a questionnaire at the beginning of the study. The questions contain information
that describes you, on HPV, cervical cancer, HPV vaccine and cervical cancer screening.
After completing the questionnaire, the researcher will give a talk on the topics or provide
you with pamphlets contain information on the topics. After listening to the health talk or
reading the pamphlets, you will be given the same questionnaire you filled in the beginning
of the study. If you choose to participate, you do not need to write your name or give any
information that will identify who you are. The questionnaire will be secured in a locked
bag and later entered into a password protected computer. The information you filled on
the questionnaire will be used for my research project. Any identifying information will be
removed. The study is expected to last no longer than 2 hours, 30 minutes.
Risk and Benefits of Participation
There are no known risks associated with this study. However, the questions may cause
you some discomfort since it involves questions about your personal practice of the HPV
and cervical cancer preventive measures. Your participation in this study will increases
your knowledge of HPV, cervical cancer, HPV vaccine and cervical cancer screening.
Also, your participation will help inform more effective approaches to increasing

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knowledge HPV and cervical cancer and uptake of the preventive measures. If you wish to
learn more about the topic confidentially, you can ask further question after the study. I am
willing and ready to answer your questions or enlighten you more on the topic.
Confidentiality
All the information that is collected will be kept strictly confidential. For the purpose of
this study, your personal identification data such as name or ID number is not needed.
However, if any detail that can identify you is written on the questionnaire, it will be
removed when entering the data. An identification number will be assigned to each survey
to protect your identity. All the information collected will be secured and will be destroyed
at the end of my doctoral program.
Voluntary Participation
Your participation in this study is voluntary. If you decide to take part you are still free to
withdraw at any time and without giving a reason. You are also free to refuse to answer
any question. There is no penalty for refusing to participate or dropping from the study.
Contacts
Please let me know if you have any questions before you agree to participate. Please let me
know if you do not understand any question or need more clarification. You may contact
me at (404) 955-6515 or by email cnkwonta@email.sc.edu if you have any study related
questions or problems.
Also, if you have questions or complaints about your treatment as a participant in this study.
If this happens, you may contact the Office of Research Compliance at the University of
South Carolina, Columbia, USA at (803) 777-7095.

Chigozie A. Nkwonta, PhD Candidate, RN/M Deanne Hilfinger-Messias, PhD, RN

College of Nursing College of Nursing
University of South Carolina University of South Carolina
Columbia, S.C. 29208 Columbia, S.C 29208
(803) 576-6021
Signatures/Dates
Your signature indicates you understood the following information:
I have read and understood the project information sheet dated 11/20/2017.
I have been given the opportunity to ask questions about the study.
I agree to take part in the study.
I understand that my taking part is voluntary.
I can withdraw from the study at any time and I will not be asked any questions about
why I no longer want to take part.
I understand my personal details such as name, phone number and address will not be
requested for this study. I will receive a copy of this form.
I will sign this form as a proof of my consent to participate.
Signatures/Dates
_____________________________________
Participants’ Name
_____________________________________
Participants’ Signature/Dates

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 APPENDIX B
QUESTIONNAIRE FOR MEN
Section A -Demographic variables
To begin, I am going to ask you a few questions about yourself
1) Age (years)________________________________
2) Marital status- Single_______ Married________ Others________
3) Highest level of education - No formal education_______ Primary education______
Secondary education_______ Tertiary education________
4) Average monthly income (#)- below 50,000____51,000-100,000___above 100,000___
Section B -Human Papilloma Virus (HPV)
5) Have you ever heard of the Human papilloma virus (HPV)? No__ Yes__ Not sure___
IF “yes” or “not sure” continue; if your answer is “no”, please go directly to question
12
6) How do you think one can get HPV (you can choose more than one answer)?
______Physical contact
______Dirty toilets
______Poor personal hygiene
______Sexual intercourse
______I don’t know
7) How do you know if someone has HPV (you can choose more than one answer)?
______Itching in the genital area
______Pain during urination
______Genital discharges
______Genital rash
______No symptoms
______I don’t know
8) Who can contract HPV?
______Male only
______Female only
______Male and female
______I don’t know
9) Which of the following increases the risk of getting HPV (you can choose more than
one answer)?
______Poor diet
______Smoking
______Poor personal hygiene
______Multiple sexual partners

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______I don’t know
10) Tick the disease you think HPV can cause?
______ Cancer of Anus
______ Cancer of cervix
______ Genital warts
______ Cancer of Penis
______ Cancer of mouth and throat
______ Cancer of Vagina
______ I don’t know
11) How likely do you think you or any of your family member will contract HPV?
Not Likely__________ Likely_____________ Very likely____________
12) Have you heard about HPV vaccine? No______ Yes_____ Not sure_______
13) Who can take the vaccine?
______Boys only
______ Girls only
______ Boys and girls
______ Adult men and women
______ Children
______I don’t know
14) Have you or anyone in your family had HPV vaccine, If Yes, who?
Me______ Wife_____ Daughter ______Son______ Others______ None______
15) How important is it for you or your family member to take HPV vaccine?
Very important __________Maybe important_________ Not important ___________
16) Do you plan to take HPV vaccine? No_________ Yes_________ Maybe_________
17) Will you encourage your family member or friends to take HPV vaccine?
No___________ Yes____________ Maybe______________
18) If yes, why will you get or encourage your family member to take up HPV vaccine?
______________________________________________________________________
19) If no, why will you not get or encourage your family member to take up HPV
vaccine?_________________________________________________________________
20) Who will you encourage to take HPV vaccine (you can choose more than one answer)?
Wife____ Daughter _____Son_____ Others_____ None_____
21) Will you pay to receive or for a family member to get HPV vaccine, If the vaccine cost
too much? No___________ Yes____________ Maybe______________

SECTION C: Cervical Cancer

Now I am going to ask you some questions about cervical cancer.
22) Have you ever heard of cervical cancer? No______ Yes______ Not sure__________
23) Which of the following do you think increases the risk of getting cervical cancer (you
can choose more than one answer)?

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______ Lack of personal hygiene
______ Poor diet
______ Hereditary (run in the family)
______ Smoking
______ Multiple sexual partners
______ I don’t know
24) Do you think cervical cancer is associated with an infection? No______ Yes_______
25) If yes in question No 20; what type of infection is cervical cancer associated with?
_______Human immunodeficiency virus (HIV) infection
_______Syphilis infection
_______Human papilloma virus (HPV) infection
_______I don’t know
26) Cervical cancer is a severe disease. No_______ Yes_______
27) Cervical cancer be prevented? No_______ Yes_______
28) Early detection of cervical cancer is helpful? No_______ Yes_______
29) How likely do you think any of your family member will develop cervical cancer
Not Likely_________ Likely_________ Very likely____________
30) Have you heard about Pap smear test or Visual Inspection with Acetic Acid (VIA)?
No________ Yes_________ Not sure___________
31) Have you heard about HPV test? No________ Yes________ Not sure________
32) Who can take Pap smear test or VIA or HPV test?
_______Men
_______Women
_______Boys
_______Girls
_______I don’t know
33) Has anyone in your family had a pap smear, If Yes, who? (you can choose more than
one answer)? Wife_______ Daughter_______ Others_______ None_______
34) How important is it for your family member to take a Pap smear test?
Not important_________ Maybe important_________ Very important____________
35) Will you encourage any of your family member to receive pap smear? No________
Yes_________ Not sure_________
36) If yes, why will you encourage your family member to receive pap smear?
_____________________________________________________________________
37) If no, why will you encourage your family member to receive pap smear?
_____________________________________________________________________
38) Will you pay for a family member to receive a pap smear; if the test cost too much?
No__________ Yes__________ Not sure_____________

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Now I am going to ask you some questions about how you see people who had HPV
infection and cervical cancer
39) Do you think people with HPV infection sleep with a lot of different people?
No_______ Yes_________ Not sure__________
40) Do you think people with cervical cancer sleep with a lot of different people?
No__________ Yes__________ Not sure__________
41) Do you think people who have (had) cervical cancer caused their problem?
No_______ Yes__________ Not sure___________
42) Do you think that a person affected by cervical cancer is disgusting?
No__________ Yes__________ Not sure___________
43) Do you feel uncomfortable around someone affected by cervical cancer?
No__________ Yes_________ Not sure___________
44) Do you believe telling someone you have (had) cervical cancer is risky?
No_________ Yes__________ Not sure___________

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 APPENDIX C
QUESTIONNAIRE FOR WOMEN
Section A -Demographic variables
To begin, I am going to ask you a few questions about yourself
1) Age (years)________________________________
2) Marital status- Single_______ Married________ Others________
3) Highest level of education - No formal education________ Primary education______
Secondary education________ Tertiary education________
4) Average monthly income (#)- below 50,000____51,000-100,000___above 100,000___
Section B -Human Papilloma Virus (HPV)
5) Have you ever heard of the Human papilloma virus (HPV)? No___ Yes___ Not sure___
IF “yes” or “not sure” continue; if your answer is “no”, please go directly to question
12
6) How do you think one can get HPV (you can choose more than one answer)?
______Physical contact
______Dirty toilets
______Poor personal hygiene
______Sexual intercourse
______I don’t know
7) How do you know if someone has HPV (you can choose more than one answer)?
______Itching in the genital area
______Pain during urination
______Genital discharges
______Genital rash
______No symptoms
______I don’t know
8) Who can contract HPV?
______Male only
______Female only
______Male and female
______I don’t know
9) Which of the following increases the risk of getting HPV (you can choose more than
one answer)?
______Poor diet
______Smoking
______Poor personal hygiene
______Multiple sexual partners

130
______I don’t know
10) Tick the disease you think HPV can cause?
______ Cancer of Anus
______ Cancer of cervix
______ Genital warts
______ Cancer of Penis
______ Cancer of mouth and throat
______ Cancer of Vagina
______ I don’t know
11) How likely do you think you or any of your family member will contract HPV?
Not Likely___________ Likely_____________ Very likely____________
12) Have you heard about HPV vaccine? No_______ Yes______ Not sure_______
13) Who can take the vaccine?
______Boys only
______ Girls only
______ Boys and girls
______ Adult men and women
______ Children
______I don’t know
14) Have you or anyone in your family had HPV vaccine, If Yes, who?
Me______ Husband_____ Son ______ Daughter ______Others _______None______
15) How important is it for you or your family member to take HPV vaccine?
Very important __________Maybe important_________ Not important ___________
16) Do you plan to take HPV vaccine? No_________ Yes_________ Maybe_________
17) Will you encourage your family member to take HPV vaccine?
No___________ Yes____________ Maybe______________
18) If yes, why will you get or encourage your family member to take up HPV vaccine?
______________________________________________________________________
19) If no, why will you not get or encourage your family member to take up HPV
vaccine?_________________________________________________________________
20) Who will you encourage to take HPV vaccine (you can choose more than one answer)?
Daughter _____Son_____ Others_____ None_____
21) Will you pay to receive or for a family member to get HPV vaccine, If the vaccine cost
too much? No____________ Yes_____________ Maybe______________
SECTION C: Cervical Cancer
Now I am going to ask you some questions about cervical cancer.
22) Have you ever heard of cervical cancer? No______ Yes______ Not sure_________
23) Which of the following do you think increases the risk of getting cervical cancer (you
can choose more than one answer)?
______ Lack of personal hygiene

131
______ Poor diet
______ Hereditary (run in the family)
______ Smoking
______ Multiple sexual partners
______ I don’t know
24) Do you think cervical cancer is associated with an infection? No______ Yes_______
25) If yes in question No 20; what type of infection is cervical cancer associated with?
_______Human immunodeficiency virus (HIV) infection
_______Syphilis infection
_______Human papilloma virus (HPV) infection
_______I don’t know
26) Cervical cancer is a severe disease. No______ Yes_______
27) Cervical cancer be prevented? No_______ Yes_______
28) Early detection of cervical cancer is helpful? No______ Yes_______
29) How likely do you think you or any of your family member will develop cervical cancer
Not Likely________ Likely________ Very likely____________
30) Have you heard about Pap smear test or Visual Inspection with Acetic Acid (VIA)?
No________ Yes_________ Not sure___________
31) Have you heard about HPV test? No________ Yes________ Not sure________
32) Who can take Pap smear test or VIA or HPV test?
_______Men
_______Women
_______Boys
_______Girls
_______I don’t know
33) Have you or anyone in your family had a pap smear, If Yes, who? (you can choose
more than one answer)? Me______ Daughter_______ Others_____ None_______
34) How important is it for you or your family member to take a Pap smear test?
Not important________ Maybe important________ Very important____________
35) Do you plan to go for cervical cancer screening? No_____ Yes____ Not sure_____
36) Will you encourage your family member to go for cervical cancer screening?
No___________ Yes____________ Maybe ______________
37) If yes, why will you encourage your family member to go for cervical cancer screening?
___________________________________________________________
38) If no, why will you encourage your family member to go for cervical cancer
screening? ______________________________________________________________

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39) Will you pay to receive or for a family member to receive a pap smear; if the test cost
too much? No__________ Yes__________ Not sure____________
40) I can only take HPV vaccine or screening with my husband’s support? No____Yes___
41) I need my husband’s permission to use health care services? No____Yes___
Now I am going to ask you some questions about how you see people who had HPV
infection and cervical cancer
42) Do you think people with HPV infection sleep with a lot of different people?
No_______ Yes_________ Not sure__________
43) Do you think people with cervical cancer sleep with a lot of different people?
No__________ Yes__________ Not sure__________
44) Do you think people who have (had) cervical cancer caused their problem?
No_______ Yes___________ Not sure___________
45) Do you think that a person affected by cervical cancer is disgusting?
No__________ Yes__________ Not sure___________
46) Do you feel uncomfortable around someone affected by cervical cancer?
No__________ Yes_________ Not sure___________
47) Do you believe telling someone you have (had) cervical cancer is risky?
No__________ Yes_________ Not sure________

133