SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA THE EFFECT OF MOBILE HEALTH COMMUNICATION INTERVENTION ON FEMALE TEACHERS’ KNOWLEDGE ON CERVICAL CANCER AND CERVICAL SCREENING UPTAKE IN ACCRA METROPOLIS BY SAMIRA ALI MUSTAPHA (10029717) THIS THESIS IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF DOCTOR OF PHILOSOPHY DEGREE IN PUBLIC HEALTH AUGUST, 2022 University of Ghana http://ugspace.ug.edu.gh ii DECLARATION I hereby declare that except for work done by others which has been duly acknowledged, this thesis is the result of my own original research carried out under the supervision of Prof. Aryeetey, Prof. Torpey and Dr Ganle. This thesis has not been submitted either in part or in whole to any other institution for the award of another degree ……………………… 23rd August, 2022 Samira Ali Mustapha (Student) Date ………………………... 23rd August, 2022 Prof Richmond Aryeetey (Principal-Supervisor) Date ………………………. 23rd August, 2022 Prof Kwesi Torpey (Co-Supervisor) Date ……………………….. 23rd August, 2022 Dr John Ganle (Co-Supervisor) Date University of Ghana http://ugspace.ug.edu.gh iii ABSTRACT Background: Cervical cancer is the fourth most frequently diagnosed cancer and the fourth leading cause of cancer death among women. Without significant intervention, the global burden is expected to increase to nearly 700,000 cases and 400,000 deaths by 2030, Ninety percent of these occur in sub-Saharan Africa including Ghana. Mobile health is an emerging technology around the world that can be effective in improving knowledge on cervical cancer and cervical cancer screening uptake. Because mobile phone adoption is growing at an exponential rate in low- and middle-income nations, employing mobile phones to promote cervical cancer services might reach a larger number of individuals in resource-constrained settings than traditional healthcare delivery methods. Objective: This study sought to assess the effect of mhealth communication intervention on female teachers’ knowledge on cervical cancer and cervical cancer screening uptake. Methodology: The study employed a cluster randomized design with baseline and endline stages. Multistage cluster randomized sampling was used to select 237 teachers from 61 private and government schools in 4 sub-districts in Accra metropolis. Two cross sectional surveys were carried out at baseline and endline across all intervention arms with control. SMS only (40), WhatsApp (50), SMS+WhatsApp (80) and Control ( 67). Questionnaire was the main tool for data collection. Modified ordinary least square regression(OLS) with Difference in Difference analysis and robust standard error were used to determine the effect of the mhealth communication intervention on cervical cancer knowledge and cervical screening uptake Results: The study assessed the effectiveness of WhatsApp only, SMS only, and WhatsApp + SMS with control on knowledge of cervical cancer and cervical cancer screening uptake. The results showed that, receiving at least one intervention, increased knowledge score on cervical cancer and overall knowledge of cervical screening by 11.5% and 19% respectively(p<0.001). Among the three interventions, WhatsApp text yielded the largest improvement on knowledge. It University of Ghana http://ugspace.ug.edu.gh iv increased knowledge on cervical cancer by 17.34% (p<0.001), Knowledge on risk factors by 18.26% (p<0.001) and overall knowledge by 17.53% (p<0.001) and the three interventions had a significant effect on knowledge on cervical cancer but did not have significant effect on cervical screening uptake Conclusion This study concludes that SMS and WhatsApp interventions had an impact on knowledge of risk factors of cervical cancer and general knowledge of cervical cancer. However, WhatsApp was the most effective in terms of raising awareness on cervical cancer University of Ghana http://ugspace.ug.edu.gh v DEDICATION I dedicate this work to my parents and siblings University of Ghana http://ugspace.ug.edu.gh vi ACKNOWLEDGEMENT I wish to acknowledge all who in diverse ways have helped with the write up of this thesis: I give God all the glory for his enabling grace to write this thesis. I wish to thank my supervisory team in the persons of Prof. Richmond Nii Aryeetey, Prof. Kwesi Torpey and Dr. John Ganle for taking time off their busy schedule to attend to my work, and for giving insightful comments and guidance. I also appreciate their patience throughout my writing of this thesis I am most grateful to the past and present deans of School of Public Health (SPH): Prof. Richard Adanu, Prof Julius Fobil and Prof Kwesi Torpey For their instrumental roles and continuous concern throughout the period of my studies. I wish to express my sincerest gratitude to all faculty members and staff of the Department of Population Family and Reproductive Health for the various assistance and expertise they contributed to this write up. I am thankful to my former and current deans of School of Nursing and Midwifery (SONM), Dr Mary Opare, Prof. Ernestina Donkor and Prof. Lydia Aziato for their concern, and encouragement throughout My PhD studies. And I also thank all my colleagues in SONM for their support. I am also indebted to the circuit supervisors overseeing the approved schools from Ghana Education Service (GES), and the Heads of all the selected schools; and all teachers who participated I also acknowledge financial assistance from the faculty endowment fund from the College of Health Sciences, University of Ghana; under the leadership of Prof Ayeh-kumi, the former Provost of the College of Health Sciences. I also thank the faculty and staff of Biostatistics Department and IT Department for their technical support and contribution to the writing of the thesis. Finally, I thank my family for their unflinching support during the tough times of my studies. I cannot extend my gratitude enough. God bless us all. University of Ghana http://ugspace.ug.edu.gh vii TABLE OF CONTENTS DECLARATION ................................................................................................................... ii ABSTRACT ......................................................................................................................... iii DEDICATION....................................................................................................................... v ACKNOWLEDGEMENT .................................................................................................... vi LIST OF TABLES............................................................................................................... xii LIST OF FIGURES ............................................................................................................ xiii LIST OF ACRONYMS ...................................................................................................... xiv DEFINITION OF TERMS .................................................................................................. xv CHAPTER ONE .................................................................................................................... 1 INTRODUCTION ................................................................................................................. 1 1.1 Background to the study .............................................................................................. 1 1.2 Problem statement ........................................................................................................ 5 1.3 Study Justification ........................................................................................................ 7 1.4 General Objective ........................................................................................................ 8 1.4.1 Specific Objectives ................................................................................................ 8 1.4.2 Research Question ................................................................................................. 8 1.4.3 Hypothesis ............................................................................................................. 8 1.5 The Conceptual Framework ......................................................................................... 9 CHAPTER TWO ................................................................................................................. 13 LITERATURE REVIEW .................................................................................................... 13 2.1 Introduction ................................................................................................................ 13 2.2 Overview of cervical cancer ...................................................................................... 13 2.3. Cervical Cancer Burden ............................................................................................ 16 2.4 Cervical Cancer Screening ......................................................................................... 18 2.4.1 Methods of Screening Test .................................................................................. 19 2.4.2 Visual inspection with acetic acid (VIA) ............................................................ 20 2.4.3 Visual inspection with Lugol’s iodine (VILI). .................................................... 20 2.4.4 Papanicolaou smear (Pap smear) ......................................................................... 22 2.4.5 HPV DNA Test ................................................................................................... 23 2.5 Factors contributing to low cervical screening uptake .............................................. 24 University of Ghana http://ugspace.ug.edu.gh viii 2.5.1 Inadequate Knowledge and Awareness ............................................................... 25 2.5.2 Perceived susceptibility ....................................................................................... 26 2.5.3 Attitude and perception towards screening uptake ............................................. 27 2.5.4. Financial barriers ................................................................................................ 29 2.5.5 Cultural beliefs and values shame around cervical cancer .................................. 29 2.6 Knowledge of cervical cancer and cervical cancer screening ................................... 30 2.7 Socio-demographic factors associated with cervical cancer screening uptake .......... 32 2.7.1 Age ...................................................................................................................... 32 2.7.2 Place of Residence: Rural versus Urban ............................................................. 34 2.7.3 Marital Status ...................................................................................................... 34 2.7.4 Educational Level ................................................................................................ 35 2.8 Prevalence of cervical cancer screening uptake ......................................................... 35 2.9 Mhealth Interventions and their use in healthcare ..................................................... 38 2.9.1 Mobile phones and their use in healthcare .......................................................... 40 2.9.2. Successful studies on the application of mhealth mobile phone in healthcare .. 43 2.9.2.1 Maternal health ................................................................................................. 44 2.9.2.2 Diabetic Self-Management and weight Management ...................................... 44 2.9.2.3 Management and control of HIV//AIDS .......................................................... 45 2.9.2.4 Health promotion .............................................................................................. 45 2.10 Effect of mhealth (SMS and WhatsApp) intervention on improving knowledge ... 46 2.11 Effect on mhealth (SMS and WhatsApp) on cervical cancer screening uptake ...... 48 2.12 Conclusion ............................................................................................................... 50 CHAPTER THREE ............................................................................................................. 51 METHODS .......................................................................................................................... 51 3.1 Study Area ................................................................................................................. 51 3.1.1 Osu Klottey ......................................................................................................... 53 3.1.2 Ayawaso .............................................................................................................. 53 3.2. Study Design ............................................................................................................. 55 3.2.1 Study Population ................................................................................................ 56 3.2.2. Inclusion Criteria ................................................................................................ 56 3.2.3. Exclusion Criteria: .............................................................................................. 57 University of Ghana http://ugspace.ug.edu.gh ix 3.2.4. Sample size calculation ...................................................................................... 57 3.2.5. Sampling technique ............................................................................................ 59 3.2.6. Data collection Technique .................................................................................. 60 3.2.6.1 Data Collection Tool ........................................................................................ 60 3.3 Pre-data Collection Activities .................................................................................... 61 3.3.1 Pre - testing .......................................................................................................... 61 3.3.2 Training of Research Assistants (Field staff) ...................................................... 61 3.3.3 School Entry ........................................................................................................ 62 3.4. Baseline cross-sectional survey ................................................................................ 62 3.4.1. SMS and WhatsApp Messaging Intervention .................................................... 63 3.4.2 End line cross- sectional survey .......................................................................... 68 3.5. Description of the SMS and WhatsApp Program ..................................................... 68 3.5.1. The Development of Messages .......................................................................... 68 3.5.2 Messages Disseminated....................................................................................... 69 3.6. Data Sources ............................................................................................................. 71 3.7 Field Work ................................................................................................................. 71 3.8 Data Set ...................................................................................................................... 72 3.8.1 Data Management ............................................................................................... 72 3.9 Statistical Methods ..................................................................................................... 73 3.9.1 Dependent Variables (Primary and Secondary Outcome Measures) .................. 73 3.9.2 Independent Variables (Other covariates) ........................................................... 74 3.9.3 Statistical Analysis .............................................................................................. 75 3.10 Quality Control ........................................................................................................ 75 3.10.1 Expert Review of Question ............................................................................... 76 3.10.2 Pre-testing .......................................................................................................... 76 3.10.3 Training of Research Assistants ........................................................................ 76 3.10.4 Ethical considerations ....................................................................................... 76 CHAPTER FOUR ............................................................................................................... 79 RESULTS ............................................................................................................................ 79 4.0 Introduction ................................................................................................................ 79 4.1 Description of the study participants, cervical cancer screening practices, knowledge University of Ghana http://ugspace.ug.edu.gh x and assessment of the balance test at baseline .......................................................... 79 4.2 Factors associated with cervical cancer uptake among female teachers in Greater Accra ......................................................................................................................... 82 4.3 Pre and post assessment of knowledge on cervical cancer ........................................ 83 4.4 Impact evaluation of the intervention on the four outcome measures (cervical cancer screening uptake, knowledge on cervical cancer, knowledge on risk factors of cervical cancer and overall knowledge): a multivariable analysis that adjust for time fixed effect ................................................................................................................ 87 4.5 Impact evaluation of the combined intervention versus control: multivariable analysis adjusting for time fixed effect ................................................................................... 89 4.6 Impact evaluation of mHealth communication intervention: Difference in differences analysis ...................................................................................................................... 91 CHAPTER FIVE ................................................................................................................. 98 DISCUSSION ...................................................................................................................... 98 5.0 Introduction ................................................................................................................ 98 5.1 The prevalence of cervical cancer screening uptake .................................................. 98 5.2 Factors associated with cervical cancer screening uptake among female teachers in the Accra Metropolis............................................................................................... 101 5.3 The effect of mHealth communication intervention on knowledge of cervical cancer among female teachers in Accra Metropolis .......................................................... 103 5.4 The effect of mHealth communication intervention on cervical cancer screening uptake among female teachers in Accra Metropolis ............................................... 106 5.5 Strengths of the study............................................................................................... 110 5.6 Limitations of the study ........................................................................................... 110 5.7 Contribution to Knowledge...................................................................................... 111 CHAPTER SIX.................................................................................................................. 112 CONCLUSION AND RECOMMENDATIONS .............................................................. 112 6.1 Conclusion ............................................................................................................... 112 6.2 Recommendations .................................................................................................... 113 REFERENCES .................................................................................................................. 114 APPENDICES ................................................................................................................... 135 University of Ghana http://ugspace.ug.edu.gh xi APPENDIX A: INFORMATION SHEET .................................................................... 135 APPENDIX B: CONSENT FORMS ............................................................................. 139 APPENDIX C: QUESTIONAIRE ................................................................................. 141 APPENDIX D: LIST OF SCHOOLS ............................................................................ 148 APPENDIX E: SENSITIVITY ANALYSIS ................................................................. 151 University of Ghana http://ugspace.ug.edu.gh xii LIST OF TABLES Table 2.1 Classification of VILLI results ..................................................................................... 21 Table 4.1: Baseline characteristics of female teachers and assessment of the balance test .......... 80 Table 4.2: Factors associated with cervical cancer uptake among female teachers in Greater Accra at baseline study showing adjusted Poisson.................................................................................. 83 Table 4.3: Knowledge assessment on cervical cancer, risk factors and screening among female teachers in Greater Accra .............................................................................................................. 85 Table 4.4: Impact evaluation of the three communication interventions on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting demographic characteristics and time of study among female teachers in Greater Accra ............................................................................ 88 Table 4.5: Impact of intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ............................... 90 Table 4.6A: Impact of intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ........................ 93 Table 4.6B: Impact of WhatsApp intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ..... 94 Table 4.6C : Impact of SMS intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ................. 95 Table 4.6D: Impact of WhatsApp and SMS intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ....................................................................................................................................................... 96 Table 4.6E: Impact of WhatsApp compared with SMS intervention on cervical cancer uptake, knowledge on cervical cancer and risk factors adjusting for time of study among female teachers in Greater Accra ............................................................................................................................ 97 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF FIGURES Figure 1.1: Conceptual Framework .............................................................................................. 12 Figure 3.1: Map of Accra Metropolis ....................................................................................... 52 Figure 3.2: Map of Ayawaso and Osu- Klottey with some selected schools ............................... 54 Figure 3.2: Picture of a phone with SMS messages..................................................................... 65 Figure 3.3: Picture of a phone with WhatsApp messages ............................................................ 66 Figure 3.4: Picture of a book given at the end of survey to teachers in control group ................. 67 University of Ghana http://ugspace.ug.edu.gh xiv LIST OF ACRONYMS AIDS - Acquired Immune Deficiency Syndrome CC - Cervical cancer CI - Confidence Interval CRUK - Cancer Research UK GARH - Greater Accra Regional Hospital GHS - Ghana Health Service GSS - GSM - Ghana Statistics Service Global System for Mobile communication HIV - Human Papilloma Virus MOH - Ministry of Health SMS - SSA - Short Message Service Sub-Saharan Africa WHO - World Health Organization University of Ghana http://ugspace.ug.edu.gh xv DEFINITION OF TERMS Client Barriers: Client barriers are individual factors that directly prevent women from participating in cervical screening programs. Health System Factors: Health system factors are barriers related to policies, structural barriers such as limited screening facilities and inadequate supply of materials that prevent the health care provider from working effectively Risk Factor: a risk factor is any feature (internal or environmental) that makes an individual more prone to developing a serious disease Knowledge: How much is known about cervical cancer and cancer screening. This was scored over 100% Prevalence of cervical screening: Refers to the proportion of female teachers who had screening done before the intervention. This was expressed in percentage No consent: Schools that did not agree to participate in the study, instantly, end their participation Consenting Schools: Schools that agree to participate in the study Perceived Barrier: One’s opinion as to what will stop them from adopting the new behaviour Perceived susceptibility: One’s belief regarding the chance of getting a condition Perceived severity: One’s conclusion of how serious a condition and its sequelae or consequences Perceived benefits: One’s belief in the efficacy of the advised action to reduce risk or seriousness Self- efficacy: Personal belief in the ability to do something University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE INTRODUCTION 1.1 Background to the study Cervical cancer (CC) presents a significant health problem to women globally. It is the fourth most common type of cancer impacting women worldwide (World health Organization(WHO), 2022). Approximately, 528,000 new cervical cancer cases and 266,000 deaths were identified in 2012 (GLOBOCAN, 2012). In 2018, an estimated 570,000 were diagnosed with cervical cancer worldwide and about 311,000 died from the disease, which accounts for 7.5% of all female cancer deaths with 70% of these occurring in developing countries ( Bray et al, 2018; Ferlay et, al 2018). In 2020, over 600,000 new cases of cervical cancer were diagnosed with 340,000 deaths around the world. Majority(90%) of deaths occurred in Low- and middle- income countries(LMIC) (WHO, 2022). Cervical cancer is common in sub- Saharan Africa, where about 35 new cases are diagnosed per 100,000 women, annually. The rate of cervical cancer deaths in Sub- Saharan Africa is ten times the rate in North America (WHO, 2013). This is largely because of a higher rate of early cervical screening in North America, resulting in dramatic decline in morbidity and mortality (NIH, 2017 In Ghana, cervical cancer is the leading cause of cancer related death and an estimated 1,500 women die from cervical cancer, annually between ages 15 and 44 years and those above 65 years. (1CO/IARC, 2017; MOH. 2015) Cervical cancer affects the cervix uteri in women (Small, Bacon, Bajaj et al., 2017). It is the result of abnormal cell growth around the cervical opening of the uterus, at the squamocolumnar junction. The cancerous cells then spread and affect surrounding tissues and organs causing severe illness and ultimately death. (Shepherd, Frampton, and Harris, 2014; Harrington et al., 2017: American Cancer Society, 2018). A preponderance of evidence supports a causal link between cervical cancer (CC) and Human University of Ghana http://ugspace.ug.edu.gh 2 Papilloma Virus (HPV). There are over a hundred species of the HPV, and about 15 of them are associated with a high risk of cervical cancer development (Denny, Quinn, Sakaranarayanan et al, 2006; Canavan & Doshi, 2000). In Ghana, cervical cancer is mostly caused by HPV types 16 and 18 (Wiredu & Armah, 2006). There are two major types of cervical cancer that have been identified. Tumours which arise from the ectocervix (outerlining) most often lead to squamous cell carcinoma, which accounts for the majority (70%) of cervical cancers. Adenocarcinoma, which arises from the mucus- secreting cells (glandular cells) of the endocervical canal constitute nearly the entirety of the remaining 30%. At the early stages, cervical cancer has no signs or symptoms hence the need for healthy women to screen (Sankaranarayanan et al, 2013, American Cancer Society 2017; Adanu, 2010). The prevention of cervical cancer depends on widespread screening and accurate diagnosis of precursor lesions, followed by appropriate triaging and implementation of therapy (Ferris et al, 2002). Regular cervical screening by women in reproductive age can reduce risk of cervical cancer incidence and mortality by 90% (WHO, 2015). Cervical screening enables early detection of pre-cancer lesions before symptoms of advanced cervical cancer are established (Stewart, 2016; Denny et al. 2013). World Health Organization recommend early screening for cervical cancer to reduce avoidable cervical cancer-related deaths and their recommendations have been adopted in many countries (WHO, 2022; Tokosi et al., 2017). However, women in sub-Saharan Africa often present with advanced stages of cervical cancer (McFarland et al., 2016; Rosser, Njoroge & Huchko, 2015). This is as a result of lack of early screening, lack of appropriate referral of women with cervical disease, HIV-HPV (human papillomavirus) co- infection, screening-related misconceptions, lack of infrastructure resources, medical, financial and a lack of awareness and education about cervical cancer among women, lack of adequate laboratory supplies, and treatment facilities (McFarland at al., 2016; Denny et al., 2013: University of Ghana http://ugspace.ug.edu.gh 3 Nwobodo & Ba-Break, 2017; Rosser, Njoroge & Huchko, 2015). In Ghana, cervical cancer screening is limited, and the screening uptake is poor due to lack of knowledge and awareness of the disease, religious and cultural belief, and financial challenges (Anaman-Torgbor, et al., 2020). These factors are contributing to the large cervical cancer burden in Ghana, and the disease is a public health concern with enormous social and economic impact (Quentin et al, 2015; Abotchie and Shokar, 2009). Simple, inexpensive, and cost-effective methods that have the ability to prevent deaths from cervical cancer have been developed and validated through numerous large-scale scientific studies (Acera et al, 2017; Campos, Tsu, Jeronimo et al; 2015: Blumenthal, et al, 2007). Visual inspection with acetic acid (VIA) and visual inspection with Lugol’s iodine (VILI) are examples of screening methods recommended for women in Low and Middle Income Countries (LMICs) (Phongsavan et al., 2014; sharma et al, 2011; Blumenthal, et al, 2007; Sankaranarayanan, Rajkumar, Cherian; et al, 2009). These methods are appealing because it is affordable, requires few resources, and can be performed by a wide range of health-care workers (physicians, nurses, midwives, local health-care workers among others). Again the results of this test are immediate, as such screening allows for a single appointment (Phongsavan et al, 2014; Solomon Lawson et al, 2012; Lynette et al, 2013; WHO, 2013). A study in Accra, about a decade ago, revealed that cervical cancer screening uptake is very low (Adanu et al, 2010). Instead of screening healthy women, most women who were screened in Ghana already had symptoms (Adanu, 2002). Previous studies further confirmed that the main factor underpinning the problem of low screening uptake in Ghana is due to poor knowledge about cervical cancer and screening (Quentin et al, 2015; Abotchie & Shokar, 2009). An integrated review on barriers to cervical cancer screening in Sub-Saharan Africa from 10 different countries, including Ghana, also confirmed low knowledge and awareness about cervical cancer and cervical screening as the main barriers (Mc Farland, 2013). University of Ghana http://ugspace.ug.edu.gh 4 Research findings suggest that introduction and implementation of mobile health (mhealth) technology could be considered as a strong influence to increase knowledge and uptake in cervical cancer screening in limited resource areas (Babirye et al, 2019; Hall et al, 2015) through awareness creation, providing information and education. (Marcolino et al, 2018; Bhatt et al, 2018; Ji et al, 2019; Babirye, et al, 2019). “MHealth communication intervention technologies play an important role in helping cancer patients to become active participants in their care. Given the ubiquity of mobile devices and the omnipresent wireless connectivity, mHealth solutions (SMS and WhatsApp) have the capability to provide just-in-time support that is both adaptive and targeted to user needs. mHealth solutions can be used to generate and share patient-centred care planning, manage late effects with cancer and its treatments, promote lifestyle and behavioral changes and assist survivors with communication with healthcare providers. Mobile applications afforded cancer patients the ability to engage with their health providers and their support networks” (Geng et al, 2015). Various mhealth communication strategies “have been developed and used to increase knowledge and adherence to cervical cancer screening uptake. This involves the use of mass media (Fornos et al. 2014), videos (Tuong et al., 2014), print materials (Austin et al. 2002), phone calls (Broberg et al., 2013) and text messages (Rashid et al. 2014) have been used to communicate the information to women. Among these strategies, mobile phone-based mhealth communication intervention (SMS and WhatsApp) have shown to have many characteristics that makes them well suited for CC screening uptake due its ability to reach large groups of people at a low cost per person, as compared to more complex interventions which may have a higher per capita cost (Hall et al, 2015). The use of phone-based mHealth provides the opportunity to improve health communication, exchange medical information, educate target populations and support data collection, even in rural and remote areas. The advantage of implementing phone-based mHealth applications in University of Ghana http://ugspace.ug.edu.gh 5 cancer screening is its cost effectiveness and easy-to-use strategy that appears to be appreciated by patients and caregivers, and which could potentially improve the quality of healthcare” (Quercia et al, 2018). For the purpose of this study, mHealth was linked to interventions using mobile phone-based communication (SMS and WhatsApp messages) for the delivery of cervical cancer health services. 1.2 Problem statement Across Sub-Saharan Africa, uptake of cervical cancer screening has been reported to be very low (Calys -Tagoe et al, 2020; Sankaranarayanan, 2014; Adanu, 2010). Recent studies suggest that the high incidence of cervical cancer in the sub- region is linked with low cervical screening uptake (Vander, 2014; Sankaranarayanan, 2014). For instance, contrary to the 70% screening coverage recommended by World Health Organization(WHO, 2021), studies among women in Accra reported that cervical screening utilization was below 3% ( Calys -Tagoe et al, 2020; Ampofo, Adumatta, Owusu, Awuviry-Newton, 2019; Adanu et al, 2002). The attendance at Greater Accra Regional Hospital the national CERVICARE unit in Accra indicate that uptake of VIA has reduced from 906 in 2016 to 646 in 2021 among the young women and Pap smear uptake among older women has increase marginally from 1183 in 2016 to 1557 in 2020. The attendance at the military hospital for both Pap smear and VIA ranges between 117 - 325 in 2017 and 2021 respectively which is very low. This has resulted in “unnecessary” (Brenan et al, 2012) and “avoidable” (Sankaranarayanan, 2014) cancer-related deaths of women across all age groups (Domfeh, Wiredu, Adjei et al, 2008). Globally, there has been a decline in the incidence of mortality of cervical cancer as a result of cervical screening as compared to other cancers (Sankaranarayanan, 2014; WHO, 2013; Sankaranarayanan et al, 2013). Despite this, uptake of screening services remains very low in sub-Saharan Africa including Ghana. University of Ghana http://ugspace.ug.edu.gh 6 In Ghana, and in some other African countries, a number of studies have examined the reasons for low cervical cancer screening uptake. From these studies, inadequate knowledge and awareness have been identified as the most common barriers to screening (Mc Farland et al, 2016; Quentin et al, 2015; Abotchie & Shokar, 2009). Other important barriers include cost, inadequate knowledge about available screening sites and lack of time and proximity to screening sites (Quentin et al, 2015; Abotchie & Shokar, 2009). Similarly, ignorance about the benefits of cervical screening has been identified as another barrier (Awua, et al, 2018; Quentin et al, 2015). From literature, one outstanding problem is how to overcome the barriers to screening uptake among women (Calys -Tagoe et al, 2020; Linde et al, 2020). A few earlier studies have attempted to address the problem of low screening uptake and inadequate knowledge: employing education, invitation letters (Eaker, Adami, and Granath , 2004; de Jonge, Cloes, Op de Beeck, et al., 2008; Acera et al, 2017) and phone calls (Rashid, Mohammed, Hamid et al., 2013; Kiran, Davies et al 2018). However, letters and telephone are expensive and difficult to scale up even though they may enhance cervical cancer screening (CCS) participation. As a result, WHO recommend short message texting (SMS) and this has promoted its adoption since it is relatively cost effective (WHO, 2021; Uy et al., 2017; Huf et al., 2020). Nevertheless, many of such studies have reported mixed results in terms of success rates, ( Stoffel, et al, 2021; Acera et al., 2017; Linde, et al., 2020; Lee et al., 2014; Albrow et al., 2014). Consequently, there is need for more innovative interventions to address the problem of inadequate knowledge and low cervical cancer screening uptake especially in low-income countries (Sabatini et al., 2016; Acera et al., 2017; Sakarayananan et al, 2014). In particular, the use of innovative communication interventions such as social media (WhatsApp) and conventional text messaging have been identified as potential strategies that University of Ghana http://ugspace.ug.edu.gh 7 could help disseminate information about cervical cancer, create awareness, and ultimately increase uptake of screening services among literate women (Osei, Appiah, Gaogli, 2021; Fortunato, et al. 2015). What is lacking at the moment however, are well designed studies that test the effects of these communication interventions (Stoffel et al., 2021; Albrow, et 2014). In Ghana for instance, there are no studies that have tested the effects of communication interventions on knowledge and uptake of cervical cancer screening services among literate populations like female teachers. There is, therefore, a need to fill this gap in knowledge given the epidemiological and public health significance of cervical cancer in many African countries, including Ghana. 1.3 Study Justification There is there is no available documented evidence of an intervention studies that has focused on SMS and WhatsApp to address the promotion of knowledge on cervical cancer and cervical screening uptake in literature in Ghana or elsewhere. This study will generate new evidence on the use of mobile health (mhealth) communication solutions specifically SMS and WhatsApp on cervical cancer screening uptake and knowledge on cervical cancer in Ghana Likewise, the findings of this study will create space for further studies to be conducted to expand the evidence base on the effectiveness of SMS text and WhatsApp text in improving cervical screening utilization and knowledge on cervical cancer. It may also influence positively health education and promotion policies Also, data on prevalence of cervical screening generated by this study will guide future public health research targeted at women and provide better understanding on the effect of communication intervention. This will enable public health researchers, scale up efforts to facilitate early diagnosis of cervical cancer to reduce mortality. University of Ghana http://ugspace.ug.edu.gh 8 1.4 General Objective To determine the effect of health communication intervention on knowledge of cervical cancer and screening uptake among female teachers in Accra Metropolis 1.4.1 Specific Objectives 1. To determine the prevalence of cervical cancer screening among female teachers in Accra Metropolis. 2. To determine factors associated with cervical cancer screening among female teachers in the Accra Metropolis. 3. To test the effect of communication intervention on knowledge of cervical cancer. 4. To determine the effect of communication intervention on cervical cancer screening uptake. 1.4.2 Research Question 1. What is the prevalence of cervical cancer screening uptake among female teachers in Accra Metropolis? 2. What are the factors associated with cervical cancer screening uptake among female teachers in Accra Metropolis? 3. What is the effect of communication intervention on knowledge of cervical cancer? 4. What is the impact of communication intervention on cervical cancer screening uptake? 1.4.3 Hypothesis This study would seek to test four hypotheses: 1. The prevalence of cervical cancer screening uptake among female teachers in Accra Metropolis will be about 12.9%. University of Ghana http://ugspace.ug.edu.gh 9 2. There is an association between the socio-demographic factors, knowledge and cervical cancer screening uptake 3. Mhealth Communication intervention will increase knowledge of cervical cancer among intervention participants compared to controls. 4. The cervical cancer screening uptake will increase significantly among teachers who received the communication intervention in comparison to controls 1.5 The Conceptual Framework Conceptual framework is an analytic tool or structure, that shows the overall organization of ideas for the study. It also shows the relevant variables and concepts and maps out the relationship amongst them that needs to be measured (Swaen, 2022; Afribary, 2020). The conceptual framework for this study was adapted from the e Health Belief Model and findings from research. The Health Belief Model has been validated and used in many studies (Costa, 2020; Namdar, Azam, Bigizadeh et al, 2012; Pribadi & Devy, 2020). The Health Belief Model was originally designed to explain failure of large numbers of eligible adults to participate in tuberculosis (TB) screening (preventive health behaviour). The Health Belief Model was considered most appropriate among other behavioural theories; because the reasons for the development of this theory in disease prevention then, is still relevant to the problem of low screening uptake which is the main exposure of interest in this study. The HBM has provided a useful framework for investigating health behaviours. It advances that, the main determinant of behaviour is the individuals belief. Which include: individual’s perception of their chances of getting a disease condition (perceived susceptibility), individual’s judgment of the severity of the disease (perceived severity), individual’s conclusion whether the new behaviour expected is better than what the he or she is already doing (perceived benefits), an individual’s opinion as to what will stop them from adopting the University of Ghana http://ugspace.ug.edu.gh 10 new behaviour (perceived barrier), factors that trigger behaviour change (cues for action) and personal belief in the ability to do something (self- efficacy). This conceptual framework shows that the constructs of the health belief model and an individual’s socio-demographic characteristics such as age, religion, marital status, level of education and parity together could predict the effect on the communication intervention(female teachers’ readiness to utilize cervical screening and vice versa (Pribadi and Devy, 2020 ; Aina, 2020; Nyangasi et al., 2018) Linking the theory to cervical screening uptake which the primary outcome of this study, the Health Belief Model (HBM) which informs this communication intervention proposes that, the female teachers’ likelihood to take up screening, depends on the level of awareness of their perceived susceptibility, and the seriousness (severity) of suffering from cervical cancer. Thus, if they think or believe they are at risk of developing cervical cancer and perceive cervical cancer is a severe disease with serious medical, social and economic consequences, then they are more likely to obtain cervical cancer screening test. On the other hand, if the female teachers hold strong conviction that CCS is not effective, and it will not benefit them, then regardless of their age, marital status, educational level and knowledge about cervical cancer and screening, they will not utilize the screening services recommended by series of messages sent by this intervention. In a similar way, perceived barrier is the most significant determining factor in behaviour change (Conner and Norman, 2022). This may include health system factors, which may be tangible and psychological, may mitigate against cervical screening uptake. Examples include high cost of test, long waiting time and proximity to screening facilities. These characteristics may prevent the female teachers from utilising the cervical screening services as desired (Conner and Norman, 2022; Aina, 2020). Evidence from studies have shown that, when the teachers(Respondents) are empowered University of Ghana http://ugspace.ug.edu.gh 11 through the mhealth communication intervention which is a series of messages developed to adequately inform them about their risk of cervical cancer, benefits of screening, burden of cervical cancer and where to go for screening (cues for action). It could increase their knowledge and thus provide the driving force and increase the likelihood of cervical screening uptake among teachers (Lemos et al, 2017; Lee et al., 2014) The health belief model has been criticized for over emphasizing on rational behaviour of clients does not consider habitual behaviours that may impact the decision-making process to accept a recommended action such as cervical screening uptake. It argues that individuals carefully weigh the barriers and benefits of behaviour. It ignores evidence from behavioural economics that stipulates that people act on impulse rather weighing the possible outcome before making a decision. In addition, individuals may not only take up screening to reduce the risk of the disease but will attend with the possibility of solving other problems. For examples, cervical screening utilization could be triggered by other factors such as accompanying a friend for screening or taking a child for consultation (Houghbaum, Becker, Rosenstock, et al., 2021; LaMorte, 2019; Gillam, 1991) Another limitation of the health belief model is that, it presumes individuals have access to equal amounts of information on a disease or illness. It does not address individual differences that could affect attention and processing of health information as well as motivational value (Houghbaum, Becker, Rosenstock, et al., 2021; LaMorte, 2019). University of Ghana http://ugspace.ug.edu.gh 12 Figure 1.1: Conceptual Framework Increase knowledge Individual factors • Perceived Susceptibility to cervical cancer • Perceived severity of cervical cancer • Perceived barrier • Age • Number of sexual partners • Marital status • Parity Knowledge • Benefits of screening for cervical cancer • Risk Factors • Causes of Cervical cancer • Burden of CC Interventions • SMS only • WhatsApp only • SMS &WhatsApp • Control Cervical screening Uptake Health system factors • Cost of screening services • Waiting Time • Proximity University of Ghana http://ugspace.ug.edu.gh 13 CHAPTER TWO LITERATURE REVIEW 2.1 Introduction This chapter presents a review of the existing literature relevant to the objectives of my study. It will include the overview of cervical cancer and current screening methodologies available to women living in developing nations. Then, an examination of the population knowledge and awareness of cervical cancer and its symptoms, screening, and treatment amongst women in Sub-Saharan Africa. This provides the context to understand factors which positively or negatively influence the uptake of cervical screening. Finally, I will present a review of existing literature on the implementation of mobile health (mHealth) in developed nations as a successful intervention to improve population knowledge and screening measures. 2.2 Overview of cervical cancer Cervical cancer, a complication of persistent Human Papilloma Virus (HPV) infection is indisputably a common cause of cancer related morbidity and mortality among women worldwide. Accounting for 3.2% of all cancers in women (Bray et al, 2018) and about 80% of cancer deaths among women in developing countries (Ferlays et al., 2015). The human papillomavirus (HPV) is a sexually transmitted infection that is easily spread. At some point in live, 50% to 80% of sexually active women are exposed to at least one HPV type (Naber et al, 2016). Cervical cancer is classified into two histological types. Adenocarcinoma and squamous cell carcinoma (SCC). SCC is more common and accounts for 70% of all cases. (Cancer Society of America, 2015). HPV has been discovered in 99.7% of cervical squamous cell cancer cases over the world (Burd, 2003; Walboomers et al, 1999). Cervical adenocarcinomas are also University of Ghana http://ugspace.ug.edu.gh 14 linked to HPV and the link is also age-dependent (Anderson, Rylander, Larsson et al, 2001). HPV was found in 89 percent of adenocarcinomas in women under the age of 40, but only 43 percent of adenocarcinomas in women 60 and older. HPV is thought to be associated to the transformation areas of abnormal cells that cause cervical cancer (American Cancer Society, 2015; Anderson, Rylander, Larsson et al, 2001). The process of developing cervical cancer starts with a risk factor. A risk factor is any attributes (individual or environmental) that makes an individual more prone to developing a serious disease (Cutler, 2002). Some risk factors cannot be controlled by the individual (exogenous/extrinsic) for example family history and age. However, with cervical cancer most identified risk factors are modifiable (lifestyle related) (Cutler, 2002). Some modifiable risk factors include: multiple sexual partners, smoking, obesity, low fruit and vegetables in-take. (Harrington et, al, 2017) Early sexual intercourse with several partners, long-term use of oral contraceptives and obesity are all predisposing factors for cervical cancer (Satija, 2015). HPV is transmitted by skin-to- skin contact during sexual activity, including vaginal, anal, and even oral sex (American Cancer Society, 2015; Satija, 2015). Women between the ages of 25 and 49, are considered the sexually active age group prone to infection by the human papillomavirus, resulting in an infected cervix (Ferlay et al, 2015; WHO, 2013). In addition, women who use combined oral contraceptives and long-acting injectable steroid contraceptives over 5–10-year period are at a higher risk of developing cervical cancer than women who do not use such (Satija, 2015). In relation to cervical cancer and precursor lesions, HPVs can also be categorized into high risk (16, 18, 31, 33, 34, 35, 39, 45, 51, 52, 56, 58, 59, 66, 68, and 70), and low risk (6, 11, 42, 43, and 44) HPV types. A systematic review and meta- analysis conducted by Ogembo et al. (2015) on the predominance of Human Papillomavirus genotypes among African women excluding University of Ghana http://ugspace.ug.edu.gh 15 women from Central Africa reveals that HPV 16, 52, 35, 18, 58, 51, 45, 31, 53 and 56 were the 10 most basic genotypes in women with atypical cervical cytology. There was a significant range of Human papillomavirus infection rates depending on location, with South Africa (57.3%) having the highest prevalence, followed by East Africa (42.8%), West Africa (27.2%), and North Africa (12.8 percent). HPV 16 and 18 were the specific strains that were found in large numbers among women with atypical cervical cytology from South Africa, with 9.9% and 5.8%, respectively, in different areas. According to the systematic review, 39 studies categorized eligible women who were tested for Human Papillomavirus infection into age categories. The group of 25–34 years old exhibited the highest HPV dominance, with 50.5 percent (95 % CI: 37.1–63.8) in these investigations. The group 15–24 years old came in second with 48.2 percent (95% CI: 14.7–81.6). HPV prevalence was 36.1 percent (95 % CI: 26.9–45.2) and 31.6 percent (95 percent CI: 14.9–48.3), respectively, in the 35–44 and 45–54- year-old groups. Data on the prevalence of HPV in Ghana's general population is currently unavailable. However, in Western Africa, where Ghana is located, roughly 4.3 percent of women in the general population are expected to have high-risk HPV-16/18 infection at any given time, and HPVs 16 and 18 are responsible for 55.6 percent of invasive cervical malignancies. (Ghana Fact Sheet on Human Papillomavirus and Related Cancers, 2018). Carrageenan a polysaccharide compound derived from seaweed and used widely in food additives, has been identified to stop HPV infection in laboratory technology. In addition, two vaccines Gardasil and Cervarix have been approved and are in use among young girls, before exposure to HPV via sexual intercourse. However, the vaccinated girls need to continue to screen for cervical cancer. This is because the available vaccines do not protect against all species of HPV that cause cervical cancer (WHO, 2021). Furthermore Metformin, a classic first line hypoglycaemic agent (drug) for type 2 diabetes has been shown to disrupt cancer growth including cervical cancer proliferation by inducing cervical cancer apoptosis (cell University of Ghana http://ugspace.ug.edu.gh 16 suicide) (Xia et al., 2020; Febbraro et al., 2014). A meta- analysis consisting of six studies reported a significant reduction in the risk of cancer death among Metformin users compared with non-users (Franciosi, 2013) 2.3. Cervical Cancer Burden Cervical cancer is a significant public health issue which presents significant disease burden to women of reproductive and middle age, among citizens living in low-resource nations (LMICs) such as sub-Saharan Africa (WHO, 2022; Bray et al. 2018). Developing nations have the greatest disease burden of cervical cancer with rate of death ranging from 10 to 35 per 100,000 persons as linked to 2 to 4 mortalities per 100,000 persons in developed nations (Arbyn et al, 2011). This disparity is due to successful national cervical cytological testing (the Papanicolaou test), which detects cell abnormalities that may indicate or precede cervical cancer. (World Health Organization, 2013). Cervical cancer is the most often diagnosed cancer and a major cause of cancer-related death among women in most SSA nations (Bray et al, 2018; Fitzmaurice et al 2017). As a result, sub- Sahara African countries have high disease burden of CC, with the disease accounting for 84- 88% percent of all deaths (Arbyn et al, 2020). It is often considered to be a disease of the poor and underprivileged (WHO, 2013; Anorlu, 2008; Nordquis & Chn 2017). Eastern and Southern Africa have one of the highest age-standardized incidence rates in the world.- Guinea with 50.9 cases per 100,000 women aged 15 to 44, Zambia with 53.7, Lesotho with 61.6, and Tanzania with 68.6 (ICO HPV Report, 2017). In Ghana, the incidence rate of cervical cancer was 24.6 cases per 100,000 women (ICO/IARC, 2018). Cervical cancer ranks as the second most frequently occurring cancer amongst women in Ghana, and the second most frequently occurring cancer amongst women between 15 and University of Ghana http://ugspace.ug.edu.gh 17 44 years of age (ICO/IARC, 2018). Adanu (2002) reported that, at the Korle–Bu Teaching Hospital, the largest teaching hospital in Ghana - 64% of all gynaecological cancers between 1995 and 1997 were cervical cancers. Additionally, Nkyekyer (2000) noted that cervical cancer was the most common form of gynaecological cancer in Ghana, constituting 57.8% of all cancers, followed by ovarian cancer. Current estimates indicate that Ghana has a population of 8.57 million women aged 15 years and older who are at risk of developing cervical cancer. In 2018 alone 3,151 women were diagnosed with cervical cancer with 2,119 resulting deaths (Bray et, al, 2018; Ghana Human Papillomavirus and Related Cancers, Fact Sheet 2018). The incidence of cervical cancer peaks in the Ashanti and Greater Accra regions, where the majority of women die within 2 years of their diagnosis (Nartey et al, 2017). It is conceivable that exposure to HPV may be occurring at younger ages in the Greater Accra region (Nartey et al, 2017). The World Health Organization (WHO) has projected future estimates of cervical cancer in Ghana through 2025 reach over 5,000 new cases, resulting in at least 3,300 deaths each year. Cervical cancer cases in Ghana, and the Sub-Saharan region at large are often diagnosed late, at advanced stages, where very little can be done (MOH, 2014; Dennya et al, 2013; Denny & Anorlu, 2012). Therefore, cervical cancer is a significant cause of mortality and morbidity among women of childbearing age, in terms of years of life lost (YLL) and years lived with disability (YLD). It also makes the largest contribution to Disability Adjusted Life Years (DALY) (Yang, Bray, Parkin et al, 2004). Effective screening programs are key elements to overcoming the burden of disease in SSA. Cervical intraepithelial neoplasm grades 2 or 3, which are precancerous lesions that, if treated, can prevent women from getting invasive cervical cancer, can be detected with early cervical cancer screening. University of Ghana http://ugspace.ug.edu.gh 18 2.4 Cervical Cancer Screening The purpose “of cervical cancer screening is to identify lesions that have the potential to become malignant and to start treatment as soon as possible (Duke et al., 2015). In developed countries, cervical screening has been demonstrated to effectively lower the incidence of cervical cancer, compared to developing nations where screening remains low, ranging from 2.0 percent to 20.2 percent in urban areas and 0.4 percent to 14.0 percent in rural areas (Karly, Silvia, & Philippe, 2009). Cervical cancer infection has a long dormant period over a decade. Once pre-cancerous lesions are found, they can be addressed on an outpatient basis, making screening important and effective. When compared to the cost of treating cervical cancer, screening is rather inexpensive (Sankaranarayanan, et al., 2013). Precancerous lesions can also be monitored in order to prevent morbidity and mortality. In Ghana, despite the fact that screening for certain malignancies such as cervical cancer is accessible and many more nurses have been trained to provide the service. These attempts to reduce the incidence and mortality of the disease in Ghana have been or unsuccessful as cases of cervical cancer increase yearly (battorcervical.org; Adanu et al., 2010, Mc Farland, 2013). Cervical cancer screening rates in Ghana are extremely low, ranging from 3.2 percent to 2.2 percent in urban and rural areas, respectively (WHO, 2008; Ayanore et al., 2020; William & Amoateng, 2012). Cervical cancer screening can be done in a variety of ways. The most typical method (Pap smear) involves taking a tiny sample of cervical tissue during a pelvic examination, for cytological analysis (Duke et al., 2015). The paucity of cervical cancer screening programs and the inadequacy of cytology-based screening programs in poorer countries are largely to blame for the high disease burden.” (Saxena, Sauvaget, & Sankaranarayanan, 2012). Cervical cancer screening should begin at age 21, with women aged 21 to 29 “years receiving screening every three years, and women aged 30-65 years receiving a Pap smear test and HPV University of Ghana http://ugspace.ug.edu.gh 19 DNA (co testing) every five years, according to new guidelines. Every three years is sufficient for a Pap smear (American College of Obstetricians and Gynecologists (ACOG), 2013). Furthermore, even if the Pap smear result is normal, the combination of Pap smear test and HPV DNA can indicate whether dysplasia will develop in the next few years in women aged 30-65.Women over 65years with no history of moderate or severe dysplasia or cervical cancer and with three negative Pap smear results in a succession are advised to stop the screening, or two negative co-test findings in a row during the last 10 years, with the most recent test completed within the last 5 years” (ACOG, 2013). The effectiveness of cervical screening is dependent on its sensitivity and specificity. Sensitivity refers to the ability of a test to accurately identify people with the disease, whereas specificity indicates the accuracy of identifying those without the disease (normal population). Sankaranarayanan (2014), in his review on cancer screening in low-and middle- income countries (LMICs), reported the general sensitivity of over 60%, and specificity of 85% for visual inspection with acetic acid 2.4.1 Methods of Screening Test The Papanicolaou (Pap) smear test, HPV DNA test, and visual inspection with acetic acid (especially in low-resource settings) are all screening tests for cervical cancer. Ablative treatments are used to treat pre-invasive cervical disease, such as burning or freezing abnormal tissue (cryotherapy) and surgical removal of aberrant tissue (WHO, 2013). However, in developing countries like Ghana, the main options of cervical cancer screening are Pap smear (cytological test), HPV DNA-based detection tests. visual inspection with acetic acid (VIA) and visual Lugol’s iodine inspection (VILI) (Sherris et al., 2009). This section discusses how these tests are conducted: University of Ghana http://ugspace.ug.edu.gh 20 2.4.2 Visual inspection with acetic acid (VIA) Visual inspection with acetic acid (VIA) and seem to be satisfactory alternative screening to cytology (Pap smear). VIA and VILI has been in use since 1990s in many LMICs (Catarino, Petignant Dongui et al., 2015). This approach does not require high technology or infrastructure. Visual inspection with acetic acid (VIA) involves the application of 3% -5% acetic acid (vinegar) to the squamocolumnar junction of the cervix. This is followed by the observation of the swabbed area under good light, preferably white light (For example, the halogen lamp). Viewing with a magnifying lens is also called visual inspection with magnifying lens/device (VIAM). This is usually performed by trained nurses and other trained paramedical staffs (WHO 2013). A positive result is given by a defined dense white patch with a rough margin which appears attached to the squamocolumnar junction. A negative test result is recorded when there is no reaction. VIA is easy, cheap and recommended for less developed countries. A new approach called “see and treat” promotes a combination of screening (VIA) and treatment (cryotherapy: Freezing precancer cells with carbon dioxide gas) for screen positive women without symptoms within a single visit (Sankaranarayanan, 2014; Sherris, 2009). Evidence from a seven (7) year VIA testing study in a rural Southern India confirmed that VIA is safe, effective and acceptable and can save lives from cervical cancer even in remote areas with few resources (Poli, et al., 2015). 2.4.3 Visual inspection with Lugol’s iodine (VILI). Visual inspection with Lugol’s Iodine (VILI) involves examining the uterine cervix under good light source. After the application of Lugol’s iodine, a positive result is ascertained by no reaction to the Lugol’s Iodine giving rise to yellow colouration. (Sankaranarayanan, 2014). Lugol’s iodine reacts with glycogen, resulting in a brown or black discoloration. Normal University of Ghana http://ugspace.ug.edu.gh 21 mature squamous epithelium contains glycogen. When the glycogen in the normal cervical cells (at the squamocolumnar junction) are in contact with Lugol’s iodine it turns black. Such a reaction is termed VILI negative. (Sankaranarayanan, 2014). Table 2.1 Classification of VILLI results VILLI Classification VILLI findings Interpretation Test Positive No reaction: Yellow discolouration of cervical cells Abnormal cervical cells Test Negative Brown or black discolouration Normal cervical cells Arbyn et al (2008) assessed the accuracy of five cervical cancer screening tests in eleven studies in Africa and India. The results showed that VILI and VIA detected the presence of cervical cancer and precancer lesions with a better accuracy than Pap smear. The results further indicated that VIA had a high sensitivity (79-83%) that correlated with colposcopy and VILI was 10% more sensitive than Pap smear. The Pap smear on the other hand, showed the lowest sensitivity (57%) and a rather high specificity of 95% (Sankaranarayanan, 2014). This finding was also confirmed by a systematic review and meta-analysis conducted in Asia by Chanthavilay, Mayxay, Phongsavan, et al, (2015). In addition, Chanthavilay et al (2015), recommended additional colposcopy and biopsy for all screened positive women in developing countries to confirm the results because of the high sensitivity and low specificity of VIA and Pap smear. This is to avoid the problem of over treatment. University of Ghana http://ugspace.ug.edu.gh 22 2.4.4 Papanicolaou smear (Pap smear) Cytology screening (Pap smear) is the oldest and the most widespread. This technique has led to effective reduction in the incidence and mortality from CC in many developed countries (Catrino et al, 2015). Papanicolaou smear is a microscopic examination of cells scraped from the squamocolumnar (SCJ) junction of the cervix; and used to detect precancerous and cancerous conditions of the cervix (Mehta, 2009). The cervix consists of columnar epithelium which lines the endocervical canal medially and squamous epithelium covers the exocervix externally. The point at which these two epithelial cells meet is called the squamocolumnar junction. It is in this area that the sample is taken for Pap -smear test (Chanthavilay et al, 2015) Pap- smear should not be performed when a woman is pregnant or menstruating. A day prior to the test, the woman taking the test must abstain from sex, vaginal medications and douching. (Mayo Clinic, 2020; Sherris, 2009). This is to avoid obscuring the epithelial cells with blood, inflammatory cells, or foreign materials such as foam or gel. During the test, the woman is placed in the lithotomy position with her legs supported. The cervix is then visualized with the aid of a speculum and a light source. The Ayre spatula is used to take the sample from the cervix, by rotating the spatula through a 360° turn for adequate sample of squamous epithelial cells and endo-cervical cells. (Chanthavilay et al, 2015) The sample is evenly distributed on a glass slide which is immediately fixed using 95% ethyl alcohol and ether to ensure appropriate preservation of the smear. There are two types of Pap- smear test kit. The traditional and the liquid based cytological kit. Pap- smear screening is indicated for sexually active women with history of at least three years of active sexual life irrespective of the age- for early screening. And stopped at age 70 years if no abnormal results is reported for the past 10 years. (Chanthavilay et al, 2015) University of Ghana http://ugspace.ug.edu.gh 23 2.4.5 HPV DNA Test HPV DNA test (HPV test) is an objective screening test which detects the presence of high risk (HR)HPV infection including HPV types 16 and 18 which cause most cases of cervical cancers. Currently, WHO recommends HPV test as first - choice screening test for women. This is because it has been proven to be more effective and efficient than Pap- smear and VIA (Mayo Clinic, 2022; WHO, 2022; WHO, 2021; Moarcas et al, 2014) HPV DNA test involves taking samples of vaginal and cervical tissue with a brush during a pelvic examination. The sample is stored in a bottle containing a liquid preservative. The same sample of cells taken can be used for both the Pap smear and the HPV test (co-testing). Current international guidelines advocate the use of HPV DNA co-testing with Pap smear (cytology) (Saslow et al., 2012). Co-testing combines the benefit of high sensitivity of HPV DNA testing with better specificity of cytology. This has improved detection rates for glandular cervical cancer and extension of the screening interval in women who test negative. Negative cytology and HPV test means risk for precancerous cervical lesions is less than 1% (Gupta et al., 2017). Therefore, HPV DNA co-testing appears to be one of the most effective strategies that governs current practice with respect to both cost and outcomes (Skroumpelos et al., 2019) DNA typing in clinical setting and the identification of HR-HPV genotypes is an important part of cervical cancer screening, as it provides the necessary evidence for the prevention and management of cervical cancer (Jamdar, et al., 2018). In studies to assess the effectiveness of HPV DNA test, Bhatla et al (2009) reported the sensitivity and specificity of HPV-DNA detection of CIN2+ disease for self-collected samples to be 82.5% and 93.6% respectively compared to 87.5% and 93.2% for physician-collected samples. Currently, the high cost of available HPV DNA test prevents the general utilization of this method of cervical cancer screening in LMICs (WHO, 2022; Martinez et al; 2020; Gupta et al, 2017) University of Ghana http://ugspace.ug.edu.gh 24 At present, there are five FDA-approved assays for HPV DNA detection: Hybrid Capture 2 (13 HR-HPV types), Cervista HPV HR test (14 HR-HPV types), Cervista HPV 16/18, Cobas 4800 HPV test (PCR-based) and Aptima HPV (amplification-based) assay, (Stoler et al., 2011). In addition, a cost-effective HPV test kit, Care HPV (Qiagen) has been evaluated in low-resource settings. Field evaluation in rural China showed the accuracy of Care HPV to be higher than VIA (Qiao et al., 2008). A multi-country evaluation of this test in India, Nicaragua and Uganda also confirmed the high sensitivity (81.5%, 76.5-85.8) and specificity (91.6%) of this test (Jeronimo et al., 2014). The availability Care HPV is expected to allow wider usage of HPV DNA testing in resource-limited countries. Furthermore, to address the problem of cost as a barrier to cervical screening utilization, a cluster randomized controlled trial in India evaluated the efficacy and cost-effectiveness of a single screening using VIA, cytology and HPV testing. The study reported that VIA was a useful alternative to HPV testing for low-resource settings, in reducing the incidence and mortality from invasive cervical cancer. Since it provided standardized testing and detection rates (Sankaranarayanan et al., 2005) 2.5 Factors contributing to low cervical screening uptake Efforts to improve cervical cancer mortality through outreach to under-screened women require an understanding of challenges women experience. It is therefore imperative to identify barriers (factors) that lead to low attendance. Understanding these factors is crucial to changing behaviours that undermine successful cervical screening uptake. Barriers that have been found to contribute to low cervical screening attendance is presented under client and health system factors in the next sub section. University of Ghana http://ugspace.ug.edu.gh 25 2.5.1 Inadequate Knowledge and Awareness Knowledge on cervical cancer and attitude towards screening play a major role in its uptake. Since awareness is the first step towards uptake. It is worrying that reports from cross-sectional studies in Ghana and other countries in Sub-Saharan Africa have, commonly identified inadequate knowledge as the major challenge to successful cervical cancer screening programmes. As a matter of fact, this is common among educated women including teachers, health workers and University staffs and students (Abotchie & Shokar, 2009; Denny & Anorlu, 2012). Consequently, inadequate knowledge noted in Sub–Saharan Africa may be an important factor contributing to the high prevalence of cervical cancer (80% of global burden) observed (WHO, 2013). For example, Ebu, et al (2015) who studied a high-risk population of HIV positive women in southern Ghana, reiterated that, almost 65% of respondents had low knowledge about cervical cancer. Similarly, a cross-sectional survey among 256 secondary school teachers in Sagamu in Ogun State in Nigeria also confirmed low knowledge. Only 24% had good knowledge. A recent integrative review involving 15 cross sectional surveys from 10 countries in sub-Saharan Africa identified limited knowledge and awareness as the most common barrier to screening uptake. In spite of the benefits of cervical screening, when most women are ignorant of these benefits, it may influence their refusal to participate (Anorlu, 2012). Previous studies demonstrate significant positive relationships between knowledge and uptake (Adanu et al., 2010; Mupepi, 2011; Emmanuel, Oluwafolahan, Moyosore, & Adebukola, 2016;). Also, Emmanuel, Oluwafolahan, Moyosore, and Sinat (2016) conducted a cross sectional study to identify the predictors and factors related to the uptake of cervical cancer screening test among female secondary school teachers in Nigeria, and reported that adequate knowledge of cervical cancer includes knowing the risk factors and signs and symptoms. An additional dimension of the commonly reported problem of inadequate knowledge of women, University of Ghana http://ugspace.ug.edu.gh 26 from studies reviewed indicated that women are disenfranchised. Despite, World Health Organization’s call to promote cervical screening uptake to reduce the burden of cervical cancer, most women in Sub-Saharan Africa including Ghana, lack awareness. Thus, they continue to report late with advanced cervical cancer (Anorlu, 2008). Among women who screen in Ghana, Adanu et al (2010) noted that, most already have symptoms suggestive of cervical cancer including abnormal vagina bleeding and painful sex This goes to show that, the first time these women hear of cervical cancer, is when they seek medical care, by which time the cancer is already advanced. This calls for intensified efforts to increase awareness and promote women in the communities, schools, market places, towns, districts and nationwide and not to assume that women will embark on cervical screening based on its immense benefits alone. 2.5.2 Perceived susceptibility According to the Health Belief Model (Perceived susceptibility), a woman’s perception about her vulnerability to contracting cervical cancer, predicts her chance of screening for cervical cancer. This was confirmed by psychological research which showed that people take up a cancer screening when they feel threatened or expect a favourable outcome (Cherry & Gans, 2018). A study by Odukoya, Oyediram and Ujomu, (2012), assessed the perceived susceptibility of women and identified none of them thought they were at risk of developing cervical cancer therefore they did not utilize the cervical screening opportunity. In addition, three cross sectional surveys noted a sense of good health or the absence of symptoms as a factor for non- attendance of cervical screening programs. The participants in all the studies cited, explained they felt no need to have a cervical screening test, since they felt healthy. (Ebu et al, 2015; Eze et al, 2012; Mupepi et al, 2011). In addition, Lee, Fog, Menon et al (2008) found a wrongly University of Ghana http://ugspace.ug.edu.gh 27 held belief among Korean American women, who thought screening was unnecessary in the absence of ill health. Good health described above as a barrier to cervical screening uptake, can be described as a fatalistic belief. That is associated with inadequate knowledge about cervical cancer (Eze et al, 2012). Cervical cancer is asymptomatic. Therefore, there is the need to screen healthy women (Adanu, 2010.) For instance, if a woman should screen only when unwell, then the screening test will invariably diagnose the cancer instead of preventing it. 2.5.3 Attitude and perception towards screening uptake Attitude has been described as the foundation of success and failure (Hasen, 2016). Attitude can affect behaviour positively or negatively (Cherry & Gans, 2018). According to the basic tenets of the health believe model, the individual’s perception informs behavioural change. For instance, earlier studies have shown that positive changes in attitude and perception about the risks and benefits of screening are associated with a greater adherence rate to recommended preventive screening procedures (Chan & So, 2015). In addition, it is known that adequate knowledge on a subject increases the tendency to assume a positive attitude (Cherry &Gans, 2018). For example, Emmanuel et al. (2018) studied 265 Teachers in Nigeria and identified a correlation between knowledge and attitude. The study results showed that, those who had heard of cervical cancer screening had a better attitude and were willing to screen for cervical cancer. Also, there was a 4% increase in the uptake of cervical screening among the intervention group (p = 0.038); whereas the control group remained essentially the same. These results further buttress the importance of awareness campaigns. However, evidence of screening uptake associated with poor knowledge exist in many developing countries (Smith et al., 2017). In fact, Alliance for Cervical Cancer Prevention (ACCP) project in rural India attributed the problem of poor attitude towards cervical screening to ignorance. As it identified University of Ghana http://ugspace.ug.edu.gh 28 that 99% of the 80,000 women recruited had never screened because their knowledge about cervical cancer and screening was generally poor (ACCP, 2014; Adageba et al., 2011). Moreover, a community study by Awua et al. (2017) in Ghana reported poor attitude of women towards screening. He reiterated that, of the 156 participants recruited in the community for screening at the hospital, only 38.5% attended. Also in another study, 361 female staffs in three health facilities in Ghana were surveyed. Although, about 75% of the respondents knew that cervical cancer could be prevented through screening, yet only 11% had ever screened at least once (Adageba et al., 2011) Furthermore, Adanu (2010) discovered among four different groups of well-educated women at the University of Ghana’s main and medical campuses in Accra, that although 39% of the respondents had sufficient knowledge about Pap smears, only about 18% had ever had a Pap smear done. In this regard, Hasahya, et, al (2016) explained from her exploratory study among women in Uganda, that even though participants had heard of cervical cancer they did not have sufficient understanding of the disease to improve their health seeking behaviour and called for the intensification of educational campaigns. Nevertheless, several studies have identified the attitude of fear of positive cervical screening test results as a barrier to cervical screening uptake. This is because it decreased the likelihood of participating in screening (Kahesa et al, 2012; Mosavel et al, 2009; Ndikom & Ofi, 2012). For example, Ebu et al, (2015) reported fear of being diagnosed with cervical cancer, deterred many women from participating in cervical screening. A study at Mama Lucy Kibaki Hospital in Nairobi by Mbaka, Waihenya, Oisebe, and Lihana (2018), stated cervical screening was hampered by a fear of tests, a lack of understanding, and a lack of faith in the process though cervical cancer screening was free In addition, Hasahya (2016) attributed the state of fear and anxiety associated with anticipated positive screening, to wrong interpretation. Also, a systematic review validated the evidence of many misconceptions among women (Hussein, Hassan and Jarat, 2016). University of Ghana http://ugspace.ug.edu.gh 29 2.5.4. Financial barriers Several studies have found that financial hurdles to cervical cancer screening exist, with many under-screened groups. Financial worries, particularly among women with limited financial resources, such as those without health insurance, may be a barrier to cervical cancer screening. (Majid et al, 2019; Adunlin et al, 2019; McAlearney et al, 2010). Despite the fact that most cancer screenings are free or low-cost, pricing cancer screenings may pose challenge to some women. Women without any health insurance cover and low-income women are less likely than those with private insurance and a higher income to have had a Pap test in the previous year (Silvera et al., 2020; Bonafede et al., 2019), Furthermore, compared to women with medical insurance, a higher proportion of women without medical insurance have a 3.5 year or longer gap between Pap tests (Bonafede et al., 2019). It's worth noting that, while one challenge to low cancer screening is due to its cost factors, the out-of-pocket expense may be unknown to some women. In a survey of women living in Appalachian counties in Ohio, for example, 81 percent said they had no idea how much a Pap test cost, 42 percent of women overestimated the cost of a Pap test (McAlearney et al, 2010). 2.5.5 Cultural beliefs and values shame around cervical cancer The cultural beliefs of some ethnic minority do not permit women to share their cervical cancer condition with each other. Because these women only talked about it with their closest friends or at home with their husbands and if someone in the immediate vicinity had been diagnosed with cancer or had died as a result of it (Lofters et al, 2017). This is because they feel that if cancer isn't discussed, it doesn't exist. It is not customary to discuss bad topics like disease or death. And if people are aware that they have a condition, they will be met with sympathy, which is unpleasant (Rimande-Joel and Ekenedo, 2019; Padela et al, 2014). Studies in Somalia of cervical cancer (CC) screening among woman revealed that, the women were not willing to University of Ghana http://ugspace.ug.edu.gh 30 test for the cancer because they believed that having CC meant that a woman or her partner had multiple sexual relationships. Having history multiple partners is not acceptable in Islam. Consequently, these women were afraid of the judgement of others. Therefore, the fear of labeling and shaming prevents them from a screening program that will possibly diagnose them with CC. Thus, keeping the subject undiscussed to prevent questions from the community and family members (Ghebre et al, 2015). 2.6 Knowledge of cervical cancer and cervical cancer screening Women's understanding of cervical cancer is quite low in many undeveloped nations (Amarin, Badria, & Obeidat, 2008). It has been shown that the vast majority of women in various nations had never heard of cervical cancer and even fewer had ever heard of cervical screening (Wong, 2009; Kidanto, Kilewo, & Moshiro, 2002). Cervical cancer can only be prevented and controlled if persons at risk are aware of the disease's risk factors, as this will allow them to avoid behaviors that increase their exposure to them. Furthermore, knowing the disease's symptoms and indicators would allow persons at risk to seek medical help earlier rather than later in the disease's progression in the less developed countries when only palliative care is possible. (WHO, 2013). Even at secondary health care centers, the long transition time from a premalignant lesion to frank cervical cancer allows for early detection and practically complete cure (Owoeye & Ibrahim 2013). However, this window of opportunity which has enabled the developed countries to reduce the incidence of cancer of the cervix would be wasted if the level of knowledge of CC screening is low (Owoeye & Ibrahim 2013). The increase cases of CC may be due to a lack of understanding about the disease, which often leads in a late detection at an advanced stage, making treatment extremely difficult (Wittet and Tsu, 2008). This is due to several reasons, “namely ignorance about the symptoms, fatalistic attitude such as readiness to attribute neoplastic disease to supernatural causes thereby resulting in delays in seeking help, University of Ghana http://ugspace.ug.edu.gh 31 fear of confirmation of suspicion and of course the perennial problem of low coverage of the population by health centre services especially the rural areas” (Owoeye & Ibrahim 2013). A study by Gyamfua et al, (2019) on the level of knowledge and related factors on CC among women revealed a significant association between the occupation and educational background of women and their level of knowledge in relation to cervical cancer uptake. Women with low or medium level of education had low level of knowledge on cervical cancer uptake whiles women with high or tertiary level of education showed a high level of knowledge on cervical cancer uptake at Bogoro community. Also, this seems to imply that people with a higher level of education have in-depth knowledge about cervical cancer. As a result, it is reasonable to assume that the more literate a community is, the more informed they will be about cervical cancer. As a result, people in industrialized countries with high literacy levels are more likely to know a lot about cervical cancer. A study of rural women in Zimbabwe found that they had little awareness of the causes, prevention, and treatment of cervical cancer. The majority of the women polled (95.78%) have never had a cervical cancer screening test (Tapera et al, 2019). Comparable research of Sudanese women found that they had little understanding of cervical cancer and how to prevent it. Despite the fact that the majority of them (78.8%) had a university degree and almost all of them (97.2%) lived in Khartoum state, Sudan, where the services are available, only a small percentage (15.8%) had had a Pap smear test (Almobarak et al, 2016). Cervical cancer risk factors, symptoms and indicators, and prevention were all poorly understood in studies conducted across Nigeria, as well as a considerably low Pap smear test uptake. 2013 (Owoeye & Ibrahim) In Ghana, Opoku et al, (2016) “found that the majority of respondents 66.7% in their study have never heard of CC. Out of 100 women who had heard about cervix cancer, 23% said they University of Ghana http://ugspace.ug.edu.gh 32 were aware of the risk factors, 17% said they were aware of the signs of cervical cancer, and 14% said they were aware of how to detect cervical cancer A study was conducted in the United States to find out women’s knowledge on HPV and cancer of the cervix. The study revealed that, knowledge about Human Papillomavirus among U.S women between the ages 18 to 75 years old was low with only 40% of women reporting having ever heard of HPV and even among those who had heard of it, less than half of the number knew that Human Papillomavirus causes cervical cancer. Their findings revealed that knowing about HPV does not predetermine one’s knowledge about its relationship with cervical cancer. Therefore, researchers in health care have the tasks of designing messages to increase recognition of the name Human Papillomavirus Virus and the acronym HPV and increase the knowledge level of the potential effects of Human Papillomavirus infection” (Tiro, Meissner, Kobrin & Chollette, 2007). 2.7 Socio-demographic factors associated with cervical cancer screening uptake Based on the literature reviewed, it is evident that demographic parameters such as level of education, age, place of residence, and marital status, among others, have a substantial impact on cervical cancer screening uptake. As a result, the current study believes it is important to look at the impact of these sociodemographic characteristics on the use of cervical cancer screening uptake in Ghana 2.7.1 Age Age has been found to be one of the most important predictors of Pap test. (Astarian, Mirzabeigi, Khezeli, 2017). However, there are mixed findings when it comes to age (Aina et al., 2020; Ifemelumma, 2019; Petkeviciene, Ivanauskiene & Klumbiene, 2018) Some findings from research suggest that younger women are more likely to seek cervical screening services University of Ghana http://ugspace.ug.edu.gh 33 than older women (Aina, Raul, Padilla, et al., 2020; Ifemelumma, 2019; Cerigo et al., 2013). While other, studies (Petkeviciene, Ivanauskiene and Klumbiene, 2018; Woldetsadik, et al, 2020; Ayanore, Adjuik, Ameko et al, 2020) present contrary view that non- attendance of cervical cancer screening was greater among young women than older women. Other studies have found no link between the age of the respondents and their use of cervix cancer screening services (Park et al 2011; Simou et al 2010). According to the study results of Park et al, (2011), age had no influence on the desire to receive CC screening. Similar findings were reported in a study conducted in Greece, which found no link between age and cervix cancer screening uptake (Simou et al., 2010). A survey in Ethiopia found that women between the ages of 40 and 49 were more likely to screen than those between the ages 18 to 29 (Woldetsadik et al., 2020). Opposing evidence suggests that screening declines with old age (Balogus, et al., 2012; Woldetsadik, et al, 2020; Ayanore, Adjuik, Ameko et al, 2020 Eaker et al 2001). In a population –based study in Sweden, it was observed that, some women would not attend cervical cancer screening test after invitation because they felt they had reached menopause (Eaker et al., 2001). To confirm this, Aina, et al., (2020) in Swaziland showed that participants who were less than 30 years of age were less likely to receive a cervical exam compared to women aged 30 years and above. Similarly, Cerigo, (2013) in Quebec, Canada demonstrated that older women (45 and above) had higher odds of inappropriate screening compared to younger women (21-29). Furthermore, older women spoke of valuing the test (Pap smear) for their daughters but not themselves. Although they understood the Pap smear test and recognised its health maintenance role (Oscarsson et al., 2008). These findings are worrisome as, cervical cancer cases tend to occur in midlife among women between the ages of 35 and 44 (American Cancer Society, 2018). Also, Cervical cancer mortality increases with age, cervical cancer is higher among women above age 40 (WHO, 2022). A population-based study in India, identified that, of the total of University of Ghana http://ugspace.ug.edu.gh 34 18,869 women screened, 50% of the women screened were between the ages of 31-40. This study’s finding is consistent with the age bracket (31-45) recommended by WHO as having the highest screening benefit. 2.7.2 Place of Residence: Rural versus Urban Studies support that women who lived in urban areas were more likely to be tested than those who lived in rural areas (Spencer, et al., 2021; Nyangasi et al., 2018; Sözmen, Unal et al., 2016). A study conducted by Nyangasi et al. (2018) in Kenyan, identified women residing in urban areas had higher screening scores, than those living in rural areas. Also, Spencer, et al (2021) observed that mother-daughter pairs that failed to engage in either screening or vaccination were more likely to reside in deprive areas. Furthermore, Sözmen, Unal et al., (2016) confirmed that living in a rural area was associated with decrease possibility of getting Pap smear and mammography 2.7.3 Marital Status According to Ebu (2018) and Tapera et al., (2019) respondents' marital status had no effect on cervical cancer screening uptake. However, a study by Sözmen, Unal et al., (2016) found being married was a strong determinant of participating in both Pap smear test and mammography compared to being single. This may be because married women have more social support and are more sexually active than single women (Acikgoz, & Ergor 2011This may be because, these group of women, have higher probability of having multiple sexual partners compared to married women. This may increase their risk of acquiring HPV infection which justify the need for them to utilize cervical screening service. University of Ghana http://ugspace.ug.edu.gh 35 2.7.4 Educational Level High educational level has been demonstrated as a strong predictor of cervical screening uptake (Aina, 2020; Nyangasi et al., 2018) A survey by Aina, (2020) among 300 women in Swaziland revealed that, women who had a tertiary education were more likely to receive a cervical screening than those with basic or no education. Also, two studies in Kenya confirmed higher education increased the likelihood to attend cervical screening (Nyangasi et al., 2018; Tiruneh, 2017). This includes a survey by Nyangasi et al., (2018) which reported, women with more formal education had higher probability to take up screening than ladies with less formal education. Also, Tiruneh, (2017) in Kenya, found that Pap smear screenings were higher in communities that had higher proportions of women with higher education Likewise, Sözmen, Unal et al., (2016), confirmed that having university degree increased the probability of obtaining Pap smear test and mammography than having high school education. Ebu (2018) studied among HIV positive women in the central region of Ghana. The study findings revealed that respondents with a high degree of education utilized cervical screening than those with only a high school diploma. This is because education leads to a greater understanding of health-related concerns, which can lead to increased use of cervical cancer screening services. Women who are educated can assess risk factors for particular diseases and favorably affect health-care decision, such as cervix cancer screening programs (Ebu, 2018). On the Contrary, Tapera et al., (2019), found educational level has no association with cervical screening uptake 2.8 Prevalence of cervical cancer screening uptake Cross-sectional survey involving 28,000 women of reproductive age from five SSA nations demonstrated significant variation and disparity in cervical cancer screening uptake throughout the region. (Ba et al, 2021). CC screening uptake was just 19.0 percent in SSA, as likened to University of Ghana http://ugspace.ug.edu.gh 36 81.1 percent in HICs, the prevalence rate at 0.7 percent was recorded in Benin. According to (Ba et al, 2021) uptake of CC screening among reproductive age women in these low-resource countries is low which indicates an increase in the rate of CC in the near future. The low incidence of cervical cancer screening in Sub-Saharan Africa (SSA) may be due to reasons being that most nations in the region face conflicting health requirements, including a high case of infectious illnesses, maternal and child health issues, and resources constraints As a result, cancer prevention strategies like HPV vaccinations and countrywide CC screening programs are given less priority (Stewart, Moodley & Walter, 2018; Gouda et, al 2019). Furthermore,