Int
ern
at
i
onal
Journ
al of
P
u
bli
c Hea
lt
h S
c
ie
nce (IJPH
S)
Vo
l.
7
, No
.
4,
Decem
ber
201
8,
pp. 2
36
~
24
7
IS
S
N: 22
52
-
8806,
D
O
I: 10
.11
591/ij
phs.
v7
i
4.150
13
236
Journ
al h
om
e
page
:
https:
//
ww
w.i
aesco
re
.c
om
/j
our
nals/
ind
ex.
php/IJP
H
S
Factors
In
fluenci
ng Utili
zation
of
Cervic
al Can
cer S
cree
nin
g
Servic
es in
Ke
n
ya: Th
e Case of
Nye
ri Cou
nty
Gicho
go Agne
s Wange
chi
1
,
David
M
acha
ri
a
2
1
Reproduc
t
ive
H
ea
l
th
Coordin
at
o
r,
N
y
er
i
Count
y
,
Ken
y
a
2
Open,
Dist
anc
e
and
e
Learni
ng
(
OD
eL
)
Campus
,
Univer
sit
y
of
N
ai
robi
,
Ken
y
a
Art
ic
le
In
f
o
ABSTR
A
CT
Art
ic
le
history:
Re
cei
ved
A
ug
13
, 201
8
Re
vised
N
ov
6
, 201
8
Accepte
d
Nov 12
, 201
8
Global
l
y
,
ce
rv
ical
ca
n
ce
r
cont
in
ues
to
be
a
m
aj
or
ca
use
of
m
orta
lit
y
an
d
m
orbidi
t
y
among wom
en
with
d
eve
lop
ing
coun
tr
ie
s a
cc
ount
ing
f
or
m
ore
tha
n
86%
of
the
de
aths
from
the
dise
ase
.
In
Ken
y
a
,
c
erv
ical
ca
n
ce
r
r
a
nks
as
the
sec
ond
m
ost
fre
quent
ca
nc
er
a
m
ong
wom
en:
reg
rettab
l
y
,
wi
th
80%
of
the
c
ase
s
pre
sen
te
d
during
the
late
stage
s
of
th
e
disea
se
when
t
he
scope
of
succ
essful
treat
m
ent
is
li
m
it
ed.
An
opportuni
ty
to
pre
v
ent
o
c
cur
ren
c
e
of
ce
rvi
ca
l
ca
nc
er
exi
sts
through
c
erv
ical
c
anc
e
r
scre
en
ing
for
ea
r
l
y
d
et
e
ct
ion
and
treatment
of
pre
ca
n
ce
rous
le
sio
ns
bef
or
e
the
se
dev
el
op
to
ca
n
ce
r
.
How
eve
r,
on
l
y
a
neg
li
gib
le
pr
oporti
on
of
wom
en
bene
fi
t
fro
m
ce
rvica
l
ca
nc
er
scre
eni
n
g
servic
es
in
d
eve
lop
ing
countries,
in
cl
uding
Ken
y
a.
The
purpose
of
thi
s
desc
ript
iv
e
surve
y
stud
y
was
to
det
ermine
the
factors
infl
uen
ci
n
g
ut
il
i
za
t
ion
of
c
erv
i
c
al
c
ancer
scre
en
ing
services;
an
d
foc
used
on
the
wom
en
see
king
m
at
ern
a
l
and
famil
y
p
lanning
services
at
Cen
tra
l
Provinci
al
Gene
ral
Hos
pital,
Ke
n
y
a
.
The
stud
y
esta
bli
sh
ed
th
at
,
as
in
m
ost
deve
lop
ing
coun
tri
es,
u
ti
l
izati
on
of
ce
rvi
cal
c
an
ce
r
scr
ee
ning
se
rvic
es
was
low,
reg
ard
l
ess
of
th
e
wom
en
’s
educ
a
ti
on
level,
aut
onom
y
in
de
ci
sion
m
aki
ng
and
even
good
famil
y
s
upport.
The
low
le
vel
of
aw
areness
on
the
nee
d
for
scr
ee
n
i
ng
servic
es
and
the
long
wa
it
ing
ti
m
e
at
the
clin
ic
for
thos
e
see
king
th
e
serv
ic
es
were
ide
n
tified
as
th
e
two
ke
y
issues
tha
t
nega
t
ivel
y
infl
uen
ce
d
the
uti
li
z
at
ion
of
the
scre
eni
ng
servic
es,
It
i
s
the
ref
ore
rec
om
m
ende
d
t
hat
th
e
Ministr
y
of
He
alth
an
d
othe
r
age
nc
ies
,
inc
lud
ing
indi
viduals
of
good
will,
co
llabora
t
e
in
desi
gnin
g
and
implementi
n
g
awa
ren
ess
ca
m
pai
gns
through
the
m
edia
an
d
othe
r
appr
opri
ate
av
enue
s,
inc
ludi
ng
one
-
to
-
one
en
count
e
r
s,
ta
rg
et
ing
bot
h
m
en
and
wo
m
en
in
th
e
comm
unit
ie
s.
It
is
al
so
rec
om
m
ende
d
tha
t
the
m
al
e
par
tn
ers
support
the
i
r
wom
en
in
a
cc
ess
ing
thi
s
vi
t
al l
if
e
-
saving
servi
ce.
Ke
yw
or
d:
Accessibil
it
y
Ce
rv
ic
al
ca
nce
r
sc
reen
i
ng
Fam
il
y sup
port
Level
of
a
wa
re
ness
Level
of
e
duca
ti
on
Copyright
©
201
8
Instit
ut
e
o
f Ad
vanc
ed
Engi
n
ee
r
ing
and
S
cienc
e
.
Al
l
rights re
serv
ed
.
Corres
pond
in
g
Aut
h
or
:
Dav
i
d
Ma
c
har
i
a
,
Op
e
n, Dista
n
c
e an
d
eLea
r
ning
(ODeL
)
Ca
m
pu
s
,
Un
i
ver
sit
y o
f Nai
r
ob
i,
K
e
ny
a
Em
a
il
:
dav
idm
acharia
39@
ho
t
m
ai
l.co
m
1.
INTROD
U
CTION
Ce
rv
ic
al
ca
nce
r
is
a
disease
that
af
fects
the
reprod
uctive
he
al
th
orga
n
of
a
w
om
an
cal
le
d
the
cer
vix
(the
orga
n
c
on
necti
ng
the
ute
ru
s
an
d
va
gin
a
).
It
is
a
slo
w
-
grow
i
ng
ca
nce
r
that
m
ay
ta
ke
te
n
(10
)
ye
a
rs
or
m
or
e
to
dev
el
op.
I
n
it
s
early
sta
ges
of
de
velo
pm
ent,
cerv
ic
al
cancer
m
ay
no
t
ha
ve
a
ny
sy
m
pto
m
,
bu
t
the
disease
can
be
identifie
d
th
rou
gh
r
eg
ular
screeni
ng.
I
n
it
s
la
te
sta
ges,
it
m
ay
pr
es
ent
irre
gu
la
r
vag
i
nal
bleedin
g,
pel
vic
pain
a
nd
ot
he
r
sym
pto
m
s
t
hat
are
c
omm
o
n
with
ot
her
re
pro
du
ct
ive
hea
lt
h
pro
blem
s
a
nd,
as
su
c
h,
m
ay
o
nly be c
onfirm
ed
t
hro
ugh
i
nv
est
i
gative sc
ree
ning
[1
]
.
The
pr
im
ary
cause
of
ce
rv
ic
al
cancer
i
s
H
um
an
Papilom
a
Vir
us
(
HPV)
.
To
bacc
o
sm
ok
in
g,
m
any
deliveries,
l
ong
-
te
rm
ho
rm
onal
con
trace
ptiv
e
us
e
an
d
co
-
in
fecti
on
w
it
h
H
I
V
ha
ve
bee
n
id
entifi
ed
as
co
fa
ct
or
s
Evaluation Warning : The document was created with Spire.PDF for Python.
IJPHS
IS
S
N: 22
52
-
8806
Factor
s Infl
ue
ncin
g Uti
li
za
ti
on o
f C
ervi
c
al
Can
cer
S
c
reen
ing
Services…
(
Gich
ogo
A
gn
es
Wa
ngechi
)
237
necessa
ry
f
or
pro
gr
e
ssio
n
fro
m
cerv
ic
al
HPV
in
fecti
on
to
cancer
[
2]. H
P
V
is
se
xual
ly
transm
itte
d.
Its p
rim
ary
pr
e
ve
ntion
st
r
at
egies
are
ba
sic
al
ly
two:
t
he
first
bein
g
HPV
vacci
na
ti
on
an
d
the
seco
nd
bein
g
healt
h
edu
cat
io
n
f
or
m
od
ific
at
ion
of
be
hav
i
or
s
as
so
ci
at
ed
with
HPV
infecti
on
su
ch
as
risky
sexu
al
beh
a
vi
or
s
,
sm
ok
ing
,
an
d
m
any
deliveries,
a
m
on
g
ot
her
s
.
Seco
nda
ry
pr
e
ven
ti
on
m
easur
es
involve
cer
vical
cancer
screeni
ng
f
or
early
detect
io
n
a
nd
t
reatm
e
nt
of
pr
eca
nc
erous
le
sio
ns
[3
]
,
[4
]
.
A
preca
ncero
us
le
s
ion
is
abno
rm
al
bo
dy
cel
ls
wh
ic
h,
if
le
ft
un
treat
ed
,
m
ay
le
ad
to
cancer
.
HPV
va
cci
nation
re
duces
cer
vical
cancer
incidenc
e
by
70%.
Howe
ver,
it
is
on
ly
ben
e
f
ic
ia
l
fo
r
w
om
e
n
w
ho
ha
ve
not
sta
rted
en
gagi
ng
in
s
ex
.
It
is
al
s
o
exp
e
ns
i
ve
an
d
hen
ce
un
a
ffo
rd
a
ble
f
or
m
os
t
wo
m
en
in
low
resou
rce
s
it
uations
[
5].
This
le
aves
be
hav
i
or
m
od
ific
at
ion
a
nd cer
vical
can
cer s
c
reen
i
ng a
s the
key alt
er
na
ti
ve
preve
ntiv
e ap
proac
hes.
The
natur
al
histor
y
of
cer
vic
al
cancer
s
ugge
sts
that
pr
eca
ncero
us
le
sio
ns
sta
rt
ab
ou
t
10
ye
ars
or
m
or
e
befor
e
c
ancer
de
velo
ps.
Pr
e
cance
rous
le
sion
s
are
tr
eat
able
w
hen
detect
ed
ea
rly
[1
]
.
The
refor
e
,
ea
rly
screeni
ng
a
nd
treatm
ent
fo
r
s
uch
le
sio
ns
is
i
m
po
rtant
f
or
pr
e
ve
ntion
of
cancer
.
Acc
ordin
g
to
the
A
m
erican
Ca
ncer
S
ociet
y,
it
is
reco
m
m
end
ed
that
e
ver
y
w
om
an
wh
o
is
sex
ually
act
ive
or
is
twenty
-
one
(
21)
or
m
or
e
ye
ars
of
age
s
houl
d
ha
ve
a
cerv
ic
al
cancer
s
creeni
ng
done
annuall
y
fo
r
th
ree
(3)
co
ns
ec
utive
ye
ars.
Th
e
first
screeni
ng
for
cerv
ic
al
cance
r
shou
l
d
be
done
a
fter
the
f
irst
sexu
al
int
ercour
se
or
at
the
age
of
21
ye
ars,
wh
ic
hev
e
r
c
om
es
first.
Af
te
r
3
ye
ars
of
norm
al
pap
sm
ear,
t
he
wo
m
an
ca
n
now
te
st
le
ss
fr
e
que
ntly
,
for
exam
ple,
on
ce
ever
y
3
ye
ars
i
f
sh
e
is
cl
assifi
ed
as
bein
g
at
low
ris
k
for
ce
rv
ic
al
cance
r;
howe
ver,
sh
e
s
hould
con
ti
nue
ye
a
rly
pap
sm
ear
if
sh
e
is
cl
assi
fied
as
bein
g
at
high
ris
k
[6
]
.
The
wo
m
en
cl
assifi
ed
as
of
hi
gh
ri
s
k
for
ce
rv
ic
al
ca
ncer
inclu
de
th
os
e
w
ho
are
H
IV
posit
ive,
th
os
e
with
a
sso
c
ia
te
d
hum
an
pa
pill
om
a
viru
s,
thos
e
with
m
ulti
ple
sexu
al
ly
par
tn
er
s,
th
os
e
with
hi
story
of
othe
r
cancers
a
nd
th
os
e
with
fam
ily
histo
ry
of
ce
rv
ic
a
l
cancer
[7]
,
[
8].
Sp
eci
fic
cer
vi
cal
cancer
scr
eenin
g
ap
proa
ches
rec
omm
e
nd
e
d
by
WHO
inclu
de
pa
p
s
m
ear
te
sts,
visu
al
te
sts
an
d
te
sts
for
HPV
in
fecti
on.
P
ap
sm
ear
in
vo
l
ves
t
he
c
ollec
ti
on
of
a
s
pecim
en
from
the
w
om
an’
s
cerv
i
x
wh
ic
h
is
ta
ken
to
the
la
borator
y
f
or
analy
sis.
It
ta
kes
about
a
week
for
the
cl
ie
nts
to
get
the
resu
lt
s.
This
ty
pe
of
s
creeni
ng
is
ef
fecti
ve
but
widely
un
a
vaila
bl
e
du
e
to
infrast
ru
ct
ural
co
nst
raints.
The
vi
su
al
appr
oach
es
,
(
vi
su
al
insp
ect
io
n
u
si
ng
acet
ic
aci
d
-
VIA)
a
nd
visu
al
ins
pect
ion
us
in
g
L
ugos
I
odine
(
V
IL
I)
,
a
re
cheap,
easy
to
le
arn
,
a
nd
are
carried
ou
t
by
the
healt
h
care
wo
r
ke
rs
at
the
cl
inic
and
do
no
t
re
qu
i
re
la
borat
or
y
infr
a
struct
ur
e
.
The
w
om
an
ge
ts
the
resu
lt
s
i
m
m
ediat
el
y.
This
m
et
ho
d
is
m
or
e
appr
opriat
e
an
d
ha
s
been
reco
m
m
end
ed fo
r
sc
reen
i
ng a
nd treat
m
ent f
or
pr
eca
ncero
us
conditi
o
ns i
n l
ow
-
res
ource
se
tt
ing
s [9],
[10].
The
t
rick
t
he
n,
as
ha
ppens
at
the
P
r
ov
i
nc
ia
l
Gen
e
ral
H
os
pital
in
Nyeri,
Ken
ya
,
is
t
o
i
ntegr
at
e
cerv
ic
al
ca
ncer
scree
ning
ser
vi
ces
in
t
he
al
re
ady
e
xisti
ng
m
at
ern
al
a
nd
c
hild
healt
h
pro
gra
m
s,
m
a
inly
in
th
e
fam
i
ly
plann
in
g
cl
inics.
Bot
h
pap
sm
ear
and
visu
al
te
sts
are
us
e
d
as
the
sc
r
eenin
g
ap
proac
hes
wit
h
vis
ual
te
st
bein
g
the
pri
m
ary
m
et
ho
d
th
at
is
carried
out
by
nurses
w
orkin
g
in
the
f
a
m
ily
plann
in
g
cl
inic.
Pap
sm
ear
is
carried
out
occ
asi
on
al
ly
, whe
n
the
docto
rs r
ecom
m
e
nd.
Evid
e
nce
f
rom
al
l
ov
er
th
e
world
co
nfi
rm
s
the
high
relat
ion
s
hip
be
tween
high
m
or
bid
it
y
an
d
m
or
ta
lity
fr
om
cerv
ic
al
ca
nce
r
with
non
-
part
ic
ipati
on
of
w
om
en
in
cer
vical
cancer
sc
ree
ning
program
s
an
d
low
scree
ning
cov
e
ra
ge
am
o
ng
the
el
igible
popu
la
ti
on,
be
it
fo
r
the
first
screening
or
f
or
the
rec
omm
end
e
d
regular
re
peat
scree
ning
[11],
[
12]
.
How
ever,
a
nd
as
would
be
e
xpect
ed,
le
vels
of
pa
rtic
ipati
on
in
th
e
screeni
ng
pro
gram
s
diff
er
a
lot
bet
ween
de
ve
lop
e
d
a
nd
de
ve
lop
in
g
c
ount
ries.
T
he
de
vel
oped
co
untrie
s
r
e
port
high
per
ce
ntag
e
of
pa
rtic
ipati
on
i
n
cer
vical
cance
r
scre
en
ing
of
ab
out
86%
a
nd
a
f
oll
ow
up
rate
of
76%
within
3
ye
a
rs
after
init
ia
l
scr
eenin
g
[13],
[14];
res
ulti
ng
i
n
high
le
vels
of
reduce
d
c
um
ul
at
ive
m
or
ta
li
t
y
rates
.
On
t
he
oth
er
ha
nd,
cer
vical
c
ance
r
c
onti
nu
e
s
to
be
a
m
ajo
r
pu
blic
healt
h
threat
to
w
ome
n
in
m
any
low
a
nd
m
edium
reso
urced
c
ountries
,
that
include
Ken
ya
,
am
ount
ing
to
ove
r
80%
of
the
world
c
er
vical
cancer
deaths
[
15]
,
[
16]
;
this
a
rising
from
la
ck
ef
f
ect
ive
cer
vical
scree
ning
pro
gr
am
,
low
u
ti
lizat
ion
of
the
li
m
it
ed
screeinin
g p
rogr
am
, and
fail
ure to
p
a
rtic
ipate
d
in
the
rec
om
m
end
e
d fo
ll
ow
up scr
ee
ning
test
[
17]
,
[18].
Stud
ie
s
f
ro
m
arou
nd
t
he
worl
d
hav
e
ide
ntifie
d
se
ver
al
key
facto
rs
t
hat
in
flue
nce
cer
vic
al
screeni
ng
beh
a
viors
am
on
gs
t
w
om
en.
A
cl
os
er
exa
m
inati
on
of
th
e
identifie
d
fa
ct
or
s
sug
gests
that
reaso
ns
for
low
util
iz
at
ion
of
cerv
ic
al
sc
ree
ning
a
re
ba
sic
al
ly
the
sam
e
in
both
de
velo
ped
an
d
de
velop
i
ng
re
gions
of
t
he
world
.
T
hese
i
den
ti
fie
d
fact
ors
c
on
sti
tute
t
he
obj
ect
ive
s
of
this
stu
dy
th
u
s
,
ens
uri
ng
that
the
stu
dy
co
ntr
ibu
te
s
to
avail
able
li
te
ratur
e
i
n
this
cru
ci
al
area
,
be
sides
s
uggesting
st
rategies
t
hat
w
ou
l
d
co
nt
rib
ute
the
pre
ve
ntion
and re
duct
ion
of cer
vical
can
cer.
2.
RESEA
R
CH MET
HO
D
The
stu
dy
adopted
a
descr
i
pt
ive
su
r
vey
desi
gn
a
nd
u
ti
li
zed
a
qu
antit
at
ive
researc
h
ap
pro
ach
by
us
e
of
a
str
ucture
d
quest
io
nn
ai
r
e
with
cl
os
e
end
e
d
quest
io
ns
to
enab
le
co
ll
ect
ion
of
qu
antit
at
ive
data
on
th
e
stud
y’s
f
our
in
dep
e
ndent
va
riables.
Also,
a
nd
as
ex
pected
f
or
this
kind
of
stud
y,
exte
ns
iv
e
re
view
of
rel
evan
t
li
te
ratur
e
was
unde
rtake
n
with
the
view
to
e
sta
blishin
g
the
key
var
ia
bles w
hose
analy
sis
would
giv
e
th
e
stud
y
a g
lo
bal
releva
nce.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N
:
2252
-
8806
IJPHS
V
ol.
7
,
No.
4
,
Decem
ber
2018:
236
–
24
7
238
The
ta
r
get
po
pu
la
ti
on
c
om
pr
ise
d
w
om
en
aged
bet
wee
n
15
an
d
60
ye
a
rs
see
king
m
ater
nal
healt
h
serv
ic
es
at
the
Ma
te
rn
al
Chi
ld
Healt
h/Fam
il
y
Plann
ing
(
MC
H
-
FP
)
Cl
inic
at
Ce
ntral
Pr
ovincia
l
G
ener
a
l
Ho
s
pital
in
Nyeri
in
the
m
on
th
of
J
une
2012,
w
he
n
the
da
ta
was
colle
ct
ed.
T
he
MC
H
-
FP
cl
inic
serv
es
a
n
aver
a
ge
of
920
wo
m
en
pe
r
m
on
t
h
[
19]
who
form
ed
the
ta
rg
et
popula
t
io
n
of
t
his
stu
dy.
A
sam
ple
of
30%
of
the
ta
r
get
popu
la
ti
on
was
rando
m
ly
sel
ect
ed
by
syst
e
m
at
ic
pic
king
e
ver
y
f
ourth
(
4
th
)
cl
ie
nt
who
cam
e
to
the
cl
inic, thus e
nsuri
ng
e
ve
ry wo
m
an
an
e
qual
a
nd in
dep
e
ndent
ch
a
nce
of
bein
g
incl
ud
e
d
i
n
t
he
stu
dy.
O
ut
of the
gr
a
nd
total
of
290
quest
io
nna
ires
that
wer
e
us
e
d
in
the
stu
dy,
287
of
the
m
wer
e
returne
d
,
am
ou
ntin
g
to
a
high
respo
ns
e
rate o
f 98.9
7
%
.
3.
RESU
LT
S
A
ND
DI
SCUS
S
ION
The
re
su
lt
s’
a
na
ly
sis
is
on
eac
h
of
the
fou
r
obj
ect
iv
es
of
the
stud
y
a
nd
is
ba
sed
on
data
sourc
e
d
f
r
om
the
287
return
ed
quest
io
nn
ai
res
.
T
he
stu
dy
find
i
ngs
are
then
rev
ie
wed
against
th
os
e
f
ro
m
si
m
il
ar
st
ud
i
e
s
arou
nd the
w
orl
d
as
fou
nd in
l
it
eratur
e
rev
ie
w.
3.1.
I
nf
lue
nce
of
w
omen
’s
le
vel of e
duc
at
i
on
This
s
ect
io
n
of
the
st
ud
y
capt
ur
es
in
form
at
i
on
on
the
high
est
le
vel
of
f
orm
al
edu
cat
io
n
achieve
d
by
the
res
pondent
s
.
The
w
om
en’
s
edu
c
at
ion
le
ve
l
was
then
c
r
os
s
ta
bula
te
d
with
the
dep
e
ndent
var
ia
ble,
nam
ely
util
iz
at
ion
of
c
erv
ic
al
cance
r
screeni
ng
se
r
vi
ces
,
to
est
ablish
the
relat
io
nship
betwee
n
these
tw
o
va
riables.
This
cr
os
s
ta
bu
la
ti
on
is
necess
ary
beca
us
e,
a
c
cordin
g
to
t
he
Un
it
ed
Nati
ons
W
orl
d
Dev
el
opm
ent
Re
po
rt
[
20
]
,
edu
cat
io
n
is
an
essen
ti
al
co
m
pone
nt to h
uma
n healt
h wh
e
r
eby ho
us
eh
olds wit
h
m
or
e e
ducat
ion en
joye
d bett
er
healt
h.
Wo
m
en
in
de
velo
ping
c
o
untrie
s
te
nd
to
be
poorl
y
edu
cat
e
d
;
a
fac
t
that
has
profo
und
ram
ific
ati
ons
on
total
qu
al
it
y
of
their
li
ves
,
i
nc
lud
in
g
bo
t
h
in
acce
ssing
healt
hcar
e
a
nd
in
he
al
th
-
seeki
ng
be
hav
i
or.
Als
o,
a
s
the
rest
of
t
his
se
ct
ion
s
hows
,
oth
e
r
stu
dies
arou
nd
the
gl
ob
e
ha
ve
rec
orde
d
a
posit
iv
e
associat
io
n
betwee
n
edu
cat
io
n
le
vel
and
util
iz
at
ion
of cer
vical
ca
nc
er s
c
reen
i
ng s
erv
ic
es am
ong wo
m
en.
3.1.1
.
Resp
ondents
le
vel
of
educati
on
Re
sp
on
den
ts
w
ere
requeste
d
to
ind
ic
at
e
their
hig
hest
le
vel
of
f
or
m
al
edu
cat
ion
.
T
heir
re
sp
onse
s
a
re
gi
ven
i
n
Table
1.
As
T
able
1
s
hows
,
the
stud
y
gro
up
co
ns
ist
ed
of
well
-
ed
ucated
wo
m
en
with
t
hr
ee
quarters
of
them
hav
i
ng
at
ta
ined
sec
onda
ry
edu
cat
io
n
a
nd
a
bove;
a
nd
only
a
ti
ny
propo
rtion
(
4.9%)
of
the
wo
m
en
with
no
form
al
ed
ucati
on.
Table
1
.
Re
s
po
nd
e
nts’ Le
vel
of Educat
io
n
Edu
catio
n
level o
f
r
esp
o
n
d
en
ts
Frequ
en
cy
Percentag
e
No
n
e
14
4
.9
Pri
m
a
r
y
level
57
1
9
.9
Seco
n
d
ary
level
139
4
8
.4
Ter
tia
ry lev
el
77
2
6
.8
Total
287
1
0
0
.0
3.1.2. Influe
nc
e of
e
d
ucati
on
l
evel on
u
tili
zat
i
on
of
c
ervic
al
c
ance
r
s
cre
ening
s
ervice
s
A
cr
os
s
ta
bula
ti
on
of
t
he
res
pondents
’
e
ducat
ion
le
vel
w
as
done
agai
nst
the
num
ber
of
th
os
e
w
ho
repor
te
d
to
ha
ving
had
prev
iou
s
te
sti
ng
f
or
ce
r
vical
cancer
,
as
s
how
n
in
Table
2.
Table
2
s
hows
th
a
t
util
iz
at
ion
of
c
erv
ic
al
cance
r
scr
eeni
ng
servic
es
am
on
g
w
om
en
was
lo
w
r
egardless of
th
ei
r
le
vel
of
e
du
cat
ion.
Th
os
e
wo
m
en
with
sec
onda
ry
ed
ucati
on
or
l
ow
e
r
ha
d
a
sli
gh
tl
y
lo
wer
uti
li
zat
ion
rate
of
ar
ound
25
%
,
against
a
sli
gh
tl
y hi
gher
rate
of
32.5%
am
on
g w
ome
n wit
h
te
rtia
ry
educat
ion
.
Howe
ver,
w
hile
acce
pting
the
fact
that
gen
e
r
al
ly
the
util
iz
a
t
ion
of
pre
ven
ti
ve
ser
vices
in
Ken
ya
a
nd
el
sewh
e
re
in
the
de
velo
ping
countries
is
lo
w,
it
would
be
naïve
not
to
apprecia
te
the
posit
ive
infl
uence
of
edu
cat
io
n
in
t
he
util
iz
at
ion
of
these
ser
vices
.
In
t
his
reg
a
r
d,
the
Ke
nyan
s
tud
y
res
onat
es
with
sim
il
ar
st
ud
ie
s
done
in B
otswa
na,
India an
d So
uth
Africa
that
co
nf
irm
that bett
er educate
d
w
om
en
wer
e
m
or
e co
ns
ci
ou
s tha
n
the
le
ss
edu
ca
te
d
on
e
s
on
ut
il
iz
ing
pr
e
ven
t
ive
healt
h
ser
vices
[20],
[
21]
,
[22]
.
Sim
il
a
rl
y,
a
stud
y
done
in
Jam
a
ic
a b
y B
a
rb
a a
nd
J
ua
nita i
n
2004 establ
ishes that of
t
he
w
om
en
who had
e
ver
receiv
ed
a
p
a
p
sm
ear
, 6
4%
of
them
had
a
seco
nd
a
ry
sc
hool
e
ducat
io
n
as
com
par
e
d
to
the
41.
5%
of
the
wo
m
en
who
had
ne
ve
r
ha
d
a
p
a
p
sm
ear.
The
correla
ti
on
bet
we
en
higher
e
du
c
at
ion
le
vel
and
increased
cer
vi
cal
cancer
scr
eenin
g
at
te
nd
a
nce
is
al
so
s
upporte
d by stu
dies in
th
e
U
nited
S
ta
te
s
an
d
Me
xico
[23],
[
24]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
IJPHS
IS
S
N: 22
52
-
8806
Factor
s Infl
ue
ncin
g Uti
li
za
ti
on o
f C
ervi
c
al
Can
cer
S
c
reen
ing
Services…
(
Gich
ogo
A
gn
es
Wa
ngechi
)
239
Table
2.
E
duca
ti
on
Le
vel
ver
s
us
Util
iz
at
ion
of Cer
vical
Cancer
Scr
ee
ning
Service
s
Level o
f
edu
catio
n
Previo
u
s cervical c
an
cer
scr
eeni
n
g
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
No
f
o
r
m
al edu
cati
o
n
3
2
1
.4
11
7
8
.8
Pri
m
a
r
y
15
2
6
.4
42
7
3
.7
Seco
n
d
ary
28
2
5
.2
111
7
4
.8
Ter
tia
ry
27
3
2
.5
52
6
7
.5
Total
71
216
287
3.2. Wo
men’
s
l
evel of
a
w
are
ness
an
d
u
tili
z
at
i
on
of
c
ervic
al
c
ance
r
s
cre
ening
s
ervice
s
A
w
om
an’
s
le
vel
of
a
wa
reness
was
m
easur
ed
on
f
our
ke
y
par
am
et
ers
nam
ely:
hav
in
g
eve
r
he
a
r
d
about cer
vical
cancer sc
ree
ni
ng servic
es;
kn
ow
le
dg
e
on
when
to
go fo
r
the
f
irst cer
vical
c
ancer scree
ning test
;
kn
ow
le
dge
on
the
ro
le
of
the
scree
ning
te
st;
and
awa
r
eness
of
ris
k
factors
of
cer
vical
cancer
.
These
par
am
et
ers
wer
e
exam
ined
separ
at
el
y
and
th
en
com
bin
ed
to
show
the
overall
le
vel
of
awar
e
ness
on
c
erv
ic
a
l
cancer
scr
ee
ni
ng servic
es.
3.2.1. Aw
are
n
ess on
e
xiste
n
ce o
f
c
er
vical
c
an
cer
s
cree
ni
ng
s
e
rvices
The
respo
nden
ts
wer
e
aske
d
wh
et
her
t
hey
had
eve
r
heard
a
bout
the
ex
ist
ence
of
ce
r
vical
cance
r
screeni
ng
se
rv
i
ces;
an
d
t
heir
r
esp
on
ses
are
re
corde
d
in
Ta
ble
3.
As
s
how
n
in
Ta
ble
3,
m
ajo
rity
(
68.
1%)
of
th
e
respo
nd
e
nt
s
ha
d pr
e
viously
hea
rd ab
out cer
vical
cance
r
sc
reen
i
ng
ser
vice
s.
Table
3
.
K
now
le
dg
e
on Cer
vi
cal
Cancer
Scre
enin
g
Se
r
vices
Previo
u
sly
h
eard o
f
cer
v
ical ca
n
ce
r
screenin
g
services
Frequ
en
cy
Percentag
e
Yes
206
6
8
.1
No
81
3
1
.9
Total
287
1
0
0
.0
3.2.2
.
Aware
n
ess on t
he
i
mp
ortance
of
a
c
ervical
c
an
cer
scree
nin
g
The
im
po
rtanc
e
of
cer
vical
cancer
sc
reen
i
ng
is
to
detect
c
hanges
on
the
cerv
ic
al
cel
ls
e
arly
and
treat
them
b
efo
re the
y dev
el
op to
c
ancer
. Respo
ndents
’
awa
re
ne
ss on
this fact
was
m
easur
ed by reque
sti
ng t
hem
to
identify
the
rol
e
of
cer
vical
cancer
sc
ree
nin
g
te
st
f
r
om
a
li
st
of
giv
e
n
cho
ic
es
,
as
rec
orde
d
in
Ta
ble
4.
As
Table
4
dem
on
strat
es,
t
he
r
esp
onde
nts’
le
vels
of
a
war
e
ness
a
bout
th
e
i
m
po
rta
nce
of
a
cer
vical
cance
r
screeni
ng
we
re
low.
O
nly
18%
of
t
he
w
ome
n
kne
w
that
the
scree
ning
w
as
m
eant
to
detect
the
pr
eca
nc
erous
le
sion
s
befo
re
they
de
velo
pe
d
int
o
canc
er
,
wh
il
e
a
whole
82%
of
t
he
w
om
en
ei
ther
ha
d
m
isc
on
cepti
on
s
or
they
d
id
not
know the
r
ole of
cerv
ic
al
ca
ncer scree
ning.
Table
4.
R
ole
of Cer
vical
Cancer
Scr
ee
ning
The role of
cer
v
ica
l cancer
s
cree
n
in
g
Frequ
en
cy
Percentag
e
To d
etect c
an
ce
r
155
5
4
.0
To d
etect a
n
d
tr
eat
chan
g
es o
n
the cer
v
ical ce
lls b
ef
o
re
t
h
ey
beco
m
e
cance
r
o
u
s
53
1
8
.5
To d
etect a
n
y
pro
b
le
m
in th
e
uteru
s
13
4
.5
To
d
etect H
IV
an
d
sex
u
ally
tr
an
s
m
itt
ed
dis
eases
4
1
.4
Do
no
t kn
o
w
62
2
1
.6
Total
287
1
0
0
.0
3.2.3
.
Aware
n
ess on
w
hen
to
g
o fo
r
c
ervic
al
c
an
cer
s
cree
ning
Ever
y
wo
m
an
shou
l
d
ha
ve
cerv
ic
al
canc
e
r
scree
ning
w
hen
sh
e
reac
he
s
21
ye
ars
of
age
,
the
n
annuall
y
fo
r
th
ree
ye
ars,
an
d
finaly
,
ever
y
three
ye
ars.
Re
sp
on
de
nts’
aw
aren
es
s
of
this
fact
was
m
eas
ur
e
d
by
requesti
ng
t
he
m
to
identify
wh
e
n
t
o
go
for
ce
rv
ic
al
ca
nc
er
sc
reen
i
ng
from
a
li
st
of
giv
e
n
c
hoic
es.
Thei
r
respo
ns
es
are
giv
e
n
in
Table
5.
Tab
le
5
s
hows
th
at
about
half
of
the
res
pondents
(
48.
4%
),
kne
w
w
he
n
they
wer
e
s
uppose
d
to
ha
ve
th
e
cerv
ic
al
cancer
sc
reen
i
ng;
w
hile
the
rest
ei
ther
did
no
t
kn
ow
or
ha
d
m
isc
on
cepti
on
s.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N
:
2252
-
8806
IJPHS
V
ol.
7
,
No.
4
,
Decem
ber
2018:
236
–
24
7
240
Table
5.
When
to Have
Cer
vical
Cancer
Scre
enin
g
W
h
en
to h
av
e ce
rv
ical
cance
r
scr
eeni
n
g
Frequ
en
cy
Percentag
e
Initial test at
21
y
e
ars,
an
n
u
ally
f
o
r
3
y
ears
and
then
every
th
ree yea
rs
139
4
8
.4
W
h
en
sh
e is hav
in
g
a
u
terus
r
ela
ted
pro
b
le
m
22
7
.7
If
sh
e has
been
bleed
in
g
ir
regu
larly
7
2
.4
If
sh
e dev
elo
p
s irr
eg
u
lar
u
n
ex
p
lain
ed
v
ag
in
al bleed
in
g
21
7
.3
An
y
ti
m
e
14
4
.8
Do
no
t kn
o
w
84
2
9
.3
Total
287
1
0
0
.0
3.2.4
.
Aware
n
ess on t
he
r
isk
f
actors
of
c
er
vical
c
an
cer
Re
sp
on
den
ts
wer
e
gi
ven
a
l
ist
of
risk
fact
or
s
of
ce
rv
ic
al
cance
r
a
nd
th
en
requested
to
ide
ntify
the
factors
know
n
to
them
.
The
responde
nts
we
re
then
put
into
three
cat
e
gor
ie
s
dep
e
nd
i
ng
on
t
he
num
ber
of
ris
k
factors
they
w
e
re
a
ble
to
i
den
t
ify
,
as
s
how
n
i
n
Ta
ble 6
.
T
abl
e
6
dem
on
strat
es
a
lo
w
le
vel o
f
awa
ren
e
ss on
risk
factors
wit
h
over
hal
f
(50.9
%)
of
the
res
pondents
ide
nt
ify
ing
only
1
-
2
risk
fact
or
s;
and
only
a
sm
all
pro
portion
(
16.
7%)
of t
he
re
sponde
nts a
ble to
identify
5
-
6
ri
sk
facto
rs for c
erv
ic
al
ca
ncer.
Table
6.
L
evel
of Aware
ness
on Ri
sk
Fact
or
s of Cer
vical
C
ancer
Level o
f
Awaren
ess
Frequ
en
cy
Percentag
e
Na
m
ed
5
-
6
risk
f
acto
rs
48
1
6
.7
Na
m
ed
3
-
4
risk
f
acto
rs
93
3
2
.4
Na
m
ed
1
-
2
risk
f
acto
rs
146
5
0
.9
Total
287
1
0
0
.0
3.2.5
.
Resp
ondents
’
o
ve
rall
l
evel of
a
w
are
ness
The
res
ponden
ts
’
ove
rall
le
ve
l
of
awa
re
nes
s
was
obta
ine
d
from
scor
es
ag
gr
e
gated
f
r
om
the
four
ind
ic
at
ors
desc
ribe
d
f
ro
m
Table
3
to
Ta
ble
6.
Re
s
ponde
nts
w
ho
ha
d
pr
e
viously
hea
rd
about
ce
rv
ic
al
cance
r
screeni
ng
ser
vi
ces
sco
red
one
point.
F
or
the
correct
an
swe
r
s
on
the
r
ole
of
cer
vical
canc
er
scree
ni
ng
te
st
an
d
wh
e
n
to
un
dert
ake
the
cerv
ic
al
cancer
scree
ning,
sh
e
sc
or
e
d
one
point
for
each.
I
n
ad
di
ti
on
,
the
res
po
nd
e
nt
was
assesse
d
on
he
r
aw
are
ne
ss
of
t
he
ris
k
f
act
or
s
for
cer
vi
cal
cancer.
If
the
res
pondent
m
entioned
5
-
6
ris
k
fa
ct
ors
sh
e
sco
red
t
hr
ee
po
i
nt
s.
If
sh
e
m
entione
d
3
-
4
ris
k
f
act
or
s,
sh
e
sc
ored
t
wo
points
and
i
f
sh
e
m
entions
1
-
2
risk
facto
r
s,
s
he
sc
or
e
d
on
e
point.
T
he
m
axi
m
u
m
po
ssible
sc
or
e
w
as
6
points.
T
he
wo
m
an’
s
le
vel
of
awar
e
ness
wa
s
con
sid
ere
d
ve
r
y
hig
h
if
sh
e
sc
or
e
d
5
points
a
nd
a
bove;
high
,
wh
e
n
sh
e
sc
ored
4
po
i
nts;
low,
if
sh
e
sc
ored
3
po
i
nts;
an
d
ve
ry
lo
w,
if
s
he
sco
red
2
po
i
nts
a
nd
bel
ow.
T
he
respo
ndents’
overall
l
evel
of
awar
e
ness
is
captu
red
in
Ta
b
le
7.
As
Table
7
cl
early
de
m
on
strat
es,
83%
of
the
resp
on
de
nts
had
a
low
le
ve
l
of
awar
e
ness on
c
erv
ic
al
cance
r
screeni
ng
se
rv
i
ces;
w
hile a ver
y s
m
al
l
p
rop
ort
ion
of
them
(
2.8 %)
h
a
d
ve
r
y high
le
vel of a
war
e
ness
.
Table
7.
Re
s
po
nd
e
nts’ O
ve
rall
Lev
el
of
A
wa
ren
es
s
on Cer
vi
cal
Cancer
Level o
f
awar
en
es
s
Frequ
en
cy
Percentag
e
Ver
y
hig
h
8
2
.8
Hig
h
41
1
4
.2
Low
88
3
0
.6
Ver
y
low
150
5
2
.4
Total
287
1
0
0
.0
3.2.6
.
Rela
tio
n
ship of
l
e
vel of
a
w
are
ness
and
p
re
vio
u
s
s
cr
eeni
ng
of
c
er
vi
cal
c
an
ce
r
Much
as
oth
e
r
factors
m
ay
influ
ence
a
w
om
an’
s
decisi
on
to
seek
the
sc
ree
ning
se
rv
ic
es
,
her
le
vel
of
awar
e
ness
,
as
detai
le
d
in
Sec
ti
on
3.2.5,
m
us
t
be
a
key
fact
or.
Acc
ordi
ng
l
y,
a
cr
os
s
ta
bu
l
at
ion
was
done
on
the
wo
m
en’
s
ove
r
al
l
le
vel
of
awar
e
ness
an
d
their
pr
e
viou
s
par
ti
ci
patio
n
in
cerv
ic
al
cancer
te
sti
ng.
Their
respo
ns
es a
re
presen
te
d
in
Ta
ble 8.
Table
8
sho
ws
that
there
wa
s
a
sign
ific
ant
associat
ion
of
wo
m
en’
s
le
ve
l
of
awar
e
nes
s
and
their
util
iz
at
ion
o
f
c
erv
ic
al
cancer
screeni
ng
se
rv
i
ces.
W
om
en
w
it
h
ver
y hig
h
le
vel o
f
awa
re
ne
ss o
n
cer
vical
cancer
screeni
ng
se
r
vi
ces
wer
e
bett
er
in
t
he
util
iz
at
ion
of
scre
enin
g
ser
vices
as
com
par
ed
to
wo
m
en
with
low
awar
e
ness
le
ve
l.
A
sig
nificant
ly
hig
h
propo
rtion
of
respo
ndents
(
75
%
)
with
ve
ry
high
le
ve
l
of
awa
re
nes
s
ha
d
been
sc
reen
e
d
for
cerv
ic
al
ca
ncer
;
w
her
ea
s
on
ly
a
ver
y
sm
al
l
pr
oport
ion
(
5.3%)
of
res
po
nd
e
nts
with
ve
ry
low
le
vels of a
war
e
ness ha
d pr
e
vi
ou
sly
bee
n
sc
r
eened f
or cer
vi
cal
cancer.
Evaluation Warning : The document was created with Spire.PDF for Python.
IJPHS
IS
S
N: 22
52
-
8806
Factor
s Infl
ue
ncin
g Uti
li
za
ti
on o
f C
ervi
c
al
Can
cer
S
c
reen
ing
Services…
(
Gich
ogo
A
gn
es
Wa
ngechi
)
241
Table
8.
Re
la
ti
on
s
hi
p of
Leve
l of A
war
e
ness
and Pre
vious
Ce
rv
ic
al
Cance
r
Sc
reen
i
ng
Levels
of
awar
en
e
ss
on
cer
v
ical ca
n
c
er
screenin
g
service
Self
-
repo
rting
on
p
revio
u
s cervical ca
n
cer
testin
g
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
Ver
y
hig
h
6
75
2
25
Hig
h
25
6
0
.9
16
3
9
.1
Low
34
3
8
.6
54
6
1
.4
Ver
y
low
8
5
.3
142
9
4
.7
Total
71
216
This
stud
y
re
ve
al
ed
that
ov
er
80
%
of
the
w
om
en
resp
on
de
nts
ha
d
lo
w
le
vels
of
awa
re
ne
ss
about
the
ro
le
of
ce
rv
ic
al
cancer
scree
ni
ng
;
hence
our
con
cl
us
io
n
that
this
ne
gativel
y
influ
e
nced
th
ei
r
util
iz
at
ion
of
t
he
screeni
ng
se
rv
i
ces.
Also,
an
d
as
con
sist
e
nt
with
stu
dies
done
in
Lat
in
A
m
erica,
Ma
la
ys
ia
,
Trinida
d,
J
a
m
ai
ca
and
Ma
la
wi
[25]
,
[
26
]
,
[27],
[28],
[
29]
,
ther
e
was
a
gen
e
r
al
belie
f
that
cerv
ic
al
cance
r
screeni
ng
is
use
d
t
o
diag
nose,
rath
er
than
to
pr
e
ven
t
cer
vical
cancer
.
Acc
ording
ly
,
m
any
wo
m
en
feared
be
ing
scree
ne
d
in
cas
e
they
are
dia
gnos
e
d
with
the
dead
ly
disease
;
a
rev
el
at
ion
t
hat
w
ou
l
d
ha
ve
adv
e
rse
s
ocial
ram
ific
at
ion
s
a
nd
sti
gm
a.
The
overall
le
vel
of
a
war
e
ne
ss
had
a
sig
ni
ficant
relat
ionship
wit
h
pr
e
vi
ou
s
util
iz
at
ion
of
cer
vical
cancer
s
cree
ni
ng.
In
Ke
nya,
f
or
exam
ple
75%
of
t
hose
w
ho
ha
d
pre
vious
sc
ree
ning
,
retu
rned
f
or
m
or
e
serv
ic
es
.
T
his
strong
relat
io
nship
bet
ween
l
evels
of
awa
re
ness
an
d
util
iz
at
ion
of
se
rv
ic
es
in
this
st
udy
is
consi
ste
nt w
it
h
sim
il
ar
stud
ie
s
don
e
in
Me
xic
o,
U
ganda a
nd
Ma
la
wi
[29],
[
30
]
,
[31
]
,
[
32
]
,
[
33
]
.
Re
gr
et
ta
bly,
in
this
stud
y,
m
any
of
t
he
w
om
en
who
we
r
e
cat
ego
rize
d
as
hav
i
ng
a
hig
h
le
vel
of
awar
e
ness
ha
d
no
t
prese
nted
them
sel
ves
fo
r
cerv
ic
al
cancer
screening.
T
his
find
i
ng
is
co
ns
ist
ent
with
a
study
done
i
n
Niger
i
a
w
her
e
28
%
of
healt
h
w
ork
ers
-
who
w
ou
l
d
be
e
xpect
ed
t
o
hav
e
go
od
knowle
dge
on
c
erv
ic
al
can
cer
a
nd
it
s
ram
ific
ation
s
-
ha
d
ne
ver
bee
n
te
ste
d
for
cer
vical
cancer
.
As
su
c
h
a
be
ha
vior
is
no
t
e
xpect
ed
from
righ
t
-
t
hinkin
g
a
du
lt
s,
m
any
w
ho
a
re
w
el
l
-
edu
cat
e
d,
ot
her
key
factors
bey
ond
a
wareness
m
us
t
be
at
play
,
as this st
ud
y
re
veals.
4.3
.
F
amily
s
upp
ort
and
u
t
il
i
z
at
ion
of
c
er
vical
c
an
cer
s
cree
ning
s
ervi
ces
This
sect
io
n
presents
the
fin
dings
on
the
infl
uen
ce
of
fa
m
ily
su
pp
or
t
on
w
om
en’
s
ut
il
iz
ation
of
cerv
ic
al
cance
r
scree
ning
serv
ic
es.
T
he
in
dicat
or
s
c
onsidere
d
inclu
de
who
m
ade
decisi
on
s
ab
out
seek
i
ng
cerv
ic
al
cance
r
scree
ning
se
rv
ic
e
s
;
sup
port
fr
om
the
m
ale
par
tne
r;
an
d
the
kind
of
s
upport
gi
ven
t
o
the
wo
m
an
to e
na
bl
e h
er
to
util
iz
e
preve
ntive
hea
lt
h
ser
vices
,
s
uc
h
as
cer
vical
c
ancer
scr
ee
ning se
rv
ic
es
.
4.3.1
.
Decisi
on
m
ak
in
g on
u
t
il
i
z
at
ion
of
c
er
vical
c
an
cer
s
cree
ning
s
ervi
ces
Re
sp
on
den
ts
wer
e
aske
d
t
o
ind
ic
at
e
t
he
pe
rson
w
ho
wa
s
res
pons
i
ble
f
or
m
aking
dec
isi
on
i
n
the
fam
i
ly
on
issu
es
relat
ing
to
m
at
ern
al
healt
h
ser
vices
,
su
c
h
as
cerv
ic
al
cancer
scre
eni
ng.
Thei
r
res
pons
es
are
pr
ese
nted
in T
able 9.
Table
9.
Pers
ons Res
pons
i
ble for
Ma
king
D
eci
sion
on See
king Cer
vical
Ca
ncer
Scree
ni
ng Se
rv
ic
es
Perso
n
r
esp
o
n
sib
le f
o
r
d
ecisio
n
m
ak
in
g
Frequ
en
cy
Percentag
es
Self
Male
p
a
rtner
Bo
th
self
and
m
ale
partn
er
Oth
er
p
erso
n
s
187
24
59
17
6
5
.2
8
.4
2
0
.6
5
.9
Total
287
100
Table
9
rec
ord
s
a
hi
gh
le
vel
of
a
uton
om
y
a
m
on
gs
t
the
stu
dy
gro
up,
e
ve
n
in
t
his
m
al
e
-
do
m
inate
d
so
ci
et
y.
A
w
hole
65.
2%
of
t
he
wo
m
en
we
re
re
spo
ns
ible
for
thei
r
decisi
on
to
seek
the
scree
ning
se
r
vices.
Ma
le
par
tne
rs’
involvem
ent
was
certai
nly
evide
nt
,
but
at
low
le
vels
,
with
only
29%
of
the
res
pondent
s
ei
the
r
involvin
g
t
heir
pa
rtners
or
th
e
m
al
es
ta
kin
g
the
decisi
ons
reg
a
rd
i
ng
the
seekin
g
ce
r
vical
cancer
scre
enin
g
serv
ic
es
.
4.3.2
.
Rela
tio
n
ship of
r
e
spon
sibi
li
ty
in
d
eci
sion
m
ak
in
g a
nd
u
tili
z
at
ion
of
s
cree
nin
g
s
ervice
s
Cros
s
ta
bula
ti
on
was
do
ne
on
respo
ns
ibil
it
y
fo
r
m
aking
decisi
on
s
a
ga
inst
util
iz
at
ion
of
cer
vical
cancer
sc
ree
nin
g
se
r
vices.
T
he
res
ults
are
presente
d
in
Ta
ble
10.
Ta
ble
10
re
veals
that,
a
m
on
g
t
he
gr
oup,
the
m
al
es
wer
e
ke
y
p
la
ye
rs
in
th
ei
r
pa
rtne
rs’
i
nvol
vem
ent
in
the
util
iz
at
ion
of
cer
vical
canc
er
scre
eni
ng
se
rv
ic
es.
A
com
bin
e
d
to
ta
l
of
53.
6%
of
the
wo
m
en
who
had
util
iz
ed
the
sc
ree
nin
g
ser
vices
re
ported
t
hat
ei
ther
t
heir
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IS
S
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IJPHS
V
ol.
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,
No.
4
,
Decem
ber
2018:
236
–
24
7
242
sp
ouses
,
or
bo
t
h
they
an
d
t
he
sp
ouses
,
had
m
ade
the
de
ci
s
ion
.
This
c
ontr
ast
s
with
the
26.
6%
util
iz
at
io
n
le
vel
of wom
en
w
ho m
ade th
e d
eci
sion o
n
t
heir o
wn.
Table
10.
Re
s
pons
i
bili
ty
f
or
Decisi
ons Ma
ki
ng
A
gainst
Ut
il
iz
at
ion
o
f
Sc
r
eenin
g
Se
r
vices
Res
p
o
n
sib
ility
f
o
r
d
ecisio
n
m
ak
in
g
Previo
u
sly
u
tilized
cer
v
ical
cancer
sc
reenin
g
serv
ices
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
Self
50
2
6
.6
138
7
3
.4
Male
p
a
rtner
8
3
3
.3
16
6
6
.7
Bo
th
self
and
partn
er
12
2
0
.3
47
7
9
.7
Oth
er
p
erso
n
s
1
10
9
90
Total
71
217
287
4.3.3
.
Form
of
supp
or
t
w
hen
s
eeki
n
g
c
er
vical
c
ance
r
s
cr
eeni
ng
s
ervice
s
Re
sp
on
den
ts
wer
e
re
quest
ed
to
ind
ic
at
e
the
form
of
su
pport
they
require
w
hen
see
king
cerv
ic
al
cancer
sc
reen
i
ng
se
rv
ic
es
.
Th
ei
r
respo
ns
es
a
re
pr
e
sente
d
in
Table
11
.
Tab
le
11
sho
ws
th
at
al
l
the
respo
nd
e
nts
need
e
d
sup
port
of
on
e
ki
nd
or
an
oth
e
r
wh
e
n
seekin
g
ce
rv
ic
al
cancer
scree
ning
se
rv
ic
es
.
The
s
uppo
rt
in
cl
ude
d
fina
nces,
esc
ort
to
the
facil
it
y,
an
d
enc
oura
gem
ent
to
seek
the
ser
vices.
Ce
rtai
nly,
and
a
ga
in
unde
rsc
or
i
ng
t
he
i
m
po
rtance
of
th
e
m
al
e
par
tner
in
this
c
ultu
rall
y
-
delic
at
e
m
at
te
r,
m
os
t
of
the
re
spo
nd
e
nts
in
dicat
ed
s
upport
would
com
e from
their m
a
le
p
art
ner
s
.
Table
11.
S
upport
Sou
gh
t
Wh
en
See
king Ce
r
vical
Ca
nce
r
S
creeni
ng Servi
ces
Fo
r
m
of
su
p
p
o
rt
g
iv
en
Frequ
en
cy
Percentag
e
Fin
an
ci
al su
p
p
o
rt
Esco
rt
to
the h
ealt
h
f
acility
Enco
u
rage
m
en
t to
seek
services
No
su
p
p
o
rt
requ
ired
186
29
32
41
6
4
.5%
1
0
.1%
1
1
.1%
1
4
.2%
Total
287
100
A
cl
os
e
r
lo
ok
at
the
evide
nc
e
in
this
sect
ion
br
i
ng
s
up
sever
al
i
ntere
sti
ng
facts
.
E
ven
t
hough
m
ajo
rity
of
the
res
pondents
ha
d
high
le
vels
of
e
ducat
io
n;
ha
d
t
he
aut
onom
y
to
m
ake
de
ci
sion
s
a
bout
wh
e
n
t
o
seek
t
he
needed
ce
rv
ic
al
ca
ncer
scree
ning
ser
vices;
an
d
ha
d
s
upport
from
their
m
a
le
par
t
ner
s
,
a
hi
gh
pro
portion
of
them
did
no
t
s
eek
the
se
rv
ic
e
s.
This
c
on
t
ras
ts
with
stu
dies
done
in
India
and
Pakista
n
wh
e
r
e
wo
m
en
’s
a
uton
om
y was f
ou
nd to
im
pr
ov
e
uptake
of r
e
pro
duct
ive
healt
h
s
erv
ic
es
[
21
]
,
[
34]
.
This
lo
w
le
vel
of
util
iz
at
ion
of
se
r
vices
am
ong
st
ud
y
wom
en
w
ho
ha
d
al
l
these
posit
ive
fact
or
s
in
their
fa
vour,
pe
rh
a
ps
s
houl
d
be
blam
ed
on
both
thei
r
lo
w
le
vel
of
aw
aren
es
s
an
d
t
he
fear
of
the
s
ti
g
m
a
associat
ed wit
h see
ki
ng preve
ntive
healt
h
se
r
vices as
oppos
ed
to
curat
ive
on
e
s.
4.4
.
Accessib
il
ity
of
c
er
vica
l
c
an
cer
s
cree
ning
s
e
rvices
This
sect
io
n
presents
fin
ding
s
on
t
he
acce
s
sibil
it
y
of
cervi
cal
cancer
scr
eenin
g
ser
vice
s
at
Ce
ntral
Pr
ovi
ncial
Ge
ne
ral
H
ospit
al
in
Nyeri.
T
he
i
nd
ic
at
ors
i
nv
e
s
ti
gated
incl
ud
e
distance
the
w
om
en
cov
e
re
d
to
the
healt
h
facil
it
y;
per
ce
ptio
n
a
bout
the
co
st;
an
d
the
am
ount
of
tim
e
the
cl
ie
nt
had
to
wait
at
t
he
cl
inic
t
o
rec
ei
ve
the ser
vice.
4.4.1
.
Dist
an
c
e
f
r
om the
h
ospi
ta
l
Re
sp
on
den
ts
wer
e
re
quest
e
d
to
in
dicat
e
t
he
distance
th
ey
had
to
co
ve
r
to
reac
h
th
e
Pr
ovincia
l
Gen
e
ral
H
ospi
ta
l.
The
re
spo
nse
s
a
re
as
i
nd
i
ca
te
d
in
Ta
ble
12.
Ta
ble
12
sh
ows
t
hat
m
a
j
ori
ty
(65.3%
)
of
t
he
wo
m
en
acce
ssing
se
rv
ic
es
f
rom
the
MC
H/F
P
cl
inic
travell
ed
no
m
or
e
than
five
(
5)
kilom
et
res
to
reach
the
ho
s
pital
;
and
only
a
s
m
al
l
pr
oport
ion
(3.1
%
)
ha
d
to
c
ov
e
r
m
or
e
than
10
km
to
the
ho
s
pi
ta
l.
The
distan
ce
to
the
hosp
it
al
w
as
then
cr
os
s
t
abu
la
te
d
with
pr
e
vious
util
iz
at
ion
of
cer
vical
cancer
scree
ning
ser
vices,
and
the
resu
lt
s a
re as
s
how
n
in
Ta
ble
13.
As
sho
wn
in
Table
13,
dista
nce
to
the
heal
th
facil
it
y
had
no
si
gn
ific
a
nt
relat
ion
s
hip
with
pr
e
v
io
us
par
ti
ci
patio
n
in
cerv
ic
al
cance
r
te
sti
ng
, as vir
tuall
y 70
% of the r
es
ponde
nts r
eco
rd
e
d no
previo
us
p
a
rtic
ip
at
io
n
in cer
vical
can
cer test
ing
re
ga
rd
le
ss
of the
d
i
sta
nce to t
he h
os
pital
.
Evaluation Warning : The document was created with Spire.PDF for Python.
IJPHS
IS
S
N: 22
52
-
8806
Factor
s Infl
ue
ncin
g Uti
li
za
ti
on o
f C
ervi
c
al
Can
cer
S
c
reen
ing
Services…
(
Gich
ogo
A
gn
es
Wa
ngechi
)
243
Table
12.
Dista
nce C
ov
e
red to
Reac
h
t
he Ho
s
pital
Distan
ce c
o
v
ered
Frequ
en
cy
Percent
0
-
5
k
m
188
6
5
.3
6
-
1
0
k
m
Ov
er
1
0
k
m
91
9
3
1
.6
3
.1
Total
287
1
0
0
.0
Table
13. Dist
ance to
the
H
ospit
al
an
d Uti
li
zat
ion
of Cer
vical
Cancer Scre
enin
g
Se
r
vices
Distan
ce to th
e ho
sp
ital
Self
-
repo
rting
on
prev
io
u
s cervical ca
n
cer
testin
g
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
0
-
5
k
m
41
2
1
.8
147
7
8
.2
6
-
1
0
k
m
28
3
0
.8
63
6
9
.2
>1
0
k
m
2
2
2
.2
7
7
7
.8
Total
71
217
287
4.4.2
.
C
os
t
of
t
he
c
ervic
al
c
ance
r
s
cree
nin
g
s
er
vice
s
The
res
ponde
nt
s
wer
e
re
ques
te
d
to
rate
the
cost
of
cer
vica
l
cancer
scr
een
ing
se
rv
ic
es
on
a
scal
e
of
ver
y
ex
pe
ns
iv
e,
ex
pen
si
ve
a
nd
fair.
Ta
ble
14
recor
ds
the
ir
respo
ns
es.
As
s
how
n
in
Table
14,
on
ly
a
s
m
al
l
nu
m
ber
of the
respo
nd
e
nts
(15%)
rat
ed
the
c
harges
f
or
scre
enin
g
se
rv
ic
es
as
ex
pe
ns
ive
.
Table
14.
Re
s
ponse
s
on Cost
of Cer
vical
Cancer
Scr
ee
ning
S
er
vices
Ratin
g
of
charges
f
o
r
screenin
g
Frequ
en
cy
Percentag
e
Ver
y
exp
en
siv
e
11
3
.8
Exp
en
siv
e
32
1
1
.1
Fair
169
5
8
.9
No
r
esp
o
n
se
75
2
6
.1
Total
287
1
0
0
.0
4.4.3
.
Rela
tio
n
ship of
c
ost r
ati
ng
and
u
tili
zat
i
on
of
c
ervic
al
c
ance
r
s
cre
ening
s
ervice
s
Cros
s
ta
bu
la
ti
on
was
done
on
c
os
t
rati
ng
a
gainst
util
iz
at
i
on
of
cer
vical
cancer
scree
ni
ng
ser
vices.
The
re
su
lt
s
ar
e
pr
ese
nte
d
in
Table
15.
Ta
ble
15
s
hows
that
cost
ha
d
lim
it
ed
influ
e
nc
e
on
util
iz
at
i
on
of
cer
vical
ca
ncer
scree
ning
se
r
vi
ces.
O
f
t
he
169
respo
nd
e
nts
who
rated
the
charges
a
s
fair,
only
34.
9%
of
them
repor
te
d
to
ha
ve
util
iz
ed
the
a
vaila
ble
scree
ni
ng
se
r
vices.
I
n
co
ntrast,
45.
5%
of
the
res
pond
e
nts
who
rated
th
e
charges a
s
very
exp
e
ns
i
ve
in
deed util
i
zed t
he
se
rv
ic
es
.
Table
15
.
Com
par
is
on
bet
wee
n
C
os
t R
at
ing
and U
ti
li
zat
ion o
f
Ce
r
vical
Ca
ncer Scree
ning
Co
st o
f
Scr
eeni
n
g
Ser
v
ices
Self
-
repo
rting
on
prev
io
u
s cervical ca
n
cer
testin
g
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
Ver
y
exp
en
siv
e
Exp
en
siv
e
Fair
No
resp
o
n
se
5
6
59
1
4
5
.5
1
8
.8
3
4
.9
1
.3
6
26
110
75
5
4
.5
8
1
.3
6
5
.1
9
8
.3
Total
71
21
6
287
4.4.3
.
Wai
ting
t
im
e
at t
he
c
li
nic
bef
ore
r
ec
ei
ving
c
er
vic
al
c
an
cer
s
cree
n
ing
s
er
vices
The
res
ponden
ts
wer
e
re
qu
e
s
te
d
to
rec
ord
t
he
ti
m
e
they
sp
ent
at
t
he
cl
inic
wait
in
g
to
receive
t
he
screeni
ng
ser
vi
ces.
Their
res
pons
es
a
ppear
in
Table
16.
As
s
how
n
in
Table
16,
a
sign
i
ficant
55%
of
t
he
respo
nd
e
nts
re
ported
t
hat
the
y
had
t
o
wait
for
½
hr.
an
d
m
or
e
to
acce
ss
cerv
ic
al
sc
re
e
ning
se
rv
ic
es
at
the
Pr
ovi
ncial
Ge
ner
al
Hospita
l.
This
repor
te
d
wait
ing
ti
m
e
was
the
n
c
ros
s
ta
bu
la
te
d
wi
th
previ
ous
ce
rv
ic
al
cancer
scree
ni
ng
. T
he res
ults are as
prese
nted
in
Ta
ble 17.
As
sho
wn
i
n
Table
17,
a
s
horter
wait
ing
t
i
m
e
was
cl
os
el
y
associat
ed
wi
th
a
hi
gh
e
r
util
iz
at
ion
of
cerv
ic
al
sc
ree
ning
se
rv
ic
es
.
A
bout
half
of
the
res
ponde
nts
who
i
den
ti
fied
t
he
wait
ing
ti
m
e
to
be
10
-
20
m
inu
te
s
util
iz
ed
the
cer
vical
cancer
sc
ree
nin
g
se
r
vices.
Th
e
util
iz
at
ion
rate
beco
m
es
poorer
a
nd
poorer
as
the
wait
ing
tim
e
i
ncr
ease
d
to
th
e
extent
that
t
ho
s
e
who
ide
nt
ifie
d
a
wait
ing
tim
e
of
m
or
e
than
an
ho
ur
nev
e
r
util
iz
ed
the se
r
vices.
Evaluation Warning : The document was created with Spire.PDF for Python.
IS
S
N
:
2252
-
8806
IJPHS
V
ol.
7
,
No.
4
,
Decem
ber
2018:
236
–
24
7
244
Table
16.
Wait
ing
Tim
e to Recei
ve
Ce
r
vical
Ca
ncer
Scree
ni
ng
W
aitin
g
ti
m
e bef
o
re
rece
iv
in
g
cance
r
testin
g
Frequ
en
cy
Percentag
e
10
-
2
0
m
in
u
tes
75
2
6
.1
21
-
3
0
m
in
u
tes
55
1
9
.2
3
0
m
in
u
tes
-
1hr
63
2
2
.0
More than
1 h
r
94
3
2
.8
Total
287
1
0
0
.0
Table
17.
Com
par
is
on of
Wai
ti
ng
Tim
e and
Util
iz
at
ion
of
Ce
rv
ic
al
Cance
r
Sc
reen
i
ng Se
rv
ic
es
W
aitin
g
ti
m
e
Self
-
repo
rting
on
prev
io
u
s cervical ca
n
cer
testin
g
Yes
No
Frequ
en
cy
%
Frequ
en
cy
%
10
-
2
0
m
in
u
tes
21
-
3
0
m
in
u
tes
31
-
6
0
m
in
u
tes
1
ho
u
r
35
18
9
0
4
6
.7
3
2
.7
17
0
40
37
54
94
5
3
.3
63
83
100
Total
71
21
7
28
7
The
st
ud
y
note
s
that
m
ajo
rit
y
(65.3%
)
of
t
he
wo
m
en
acc
essing
ser
vices
from
the
MC
H/FP
cl
inic
travell
ed
no
m
or
e
t
han
fi
ve
(
5)
kilom
et
res
to
reac
h
t
he
hosp
it
al
an
d
only
22%
of
t
he
w
om
en
travell
ed
for
10
km
or
m
or
e.
D
espite
this
fact
,
70%
of
the
r
esp
onde
nts
rec
orde
d
no
previ
ou
s
pa
rtic
ipati
on
in
ce
rv
ic
al
cance
r
screen
i
ng
reg
a
rd
le
ss
of
the
di
sta
nce
to
the
hosp
it
al
.
This
find
i
ng
c
on
t
rasts
stud
ie
s
done
i
n
Me
xico
[
35]
;
So
ut
h
East
Asia
,
[
36]
;
and
Wester
n
Ken
ya
,
[
37
]
;
that
point
to
t
he
long
dista
nc
es
travell
ed
by
cl
ie
nts
as
ne
ga
ti
vel
y
influ
e
ncin
g
t
he
ir
util
iz
at
ion
of
the a
vaila
ble
s
creeni
ng servic
es.
The
st
ud
y
has
al
so
sho
wn
that
the
re
was
no
si
gn
i
fican
t
associat
io
n
betwee
n
direct
cost
of
th
e
cerv
ic
al
cance
r
te
sts
and
the
util
iz
at
ion
of
the
ser
vice.
Thi
s
con
tra
sts
with
fin
dings
f
rom
stud
ie
s
in
Wester
n
Ken
ya
,
[
37
]
;
a
nd
from
Me
xico
,
[23];
that
est
ablishe
d
tha
t
cost
of
ser
vi
ces
ha
d
an
i
nfl
uen
ce
on
w
om
en’
s
util
iz
at
ion
of a
ppr
opriat
e h
eal
th care
ser
vice
s.
Finall
y,
the
se
ct
ion
c
on
si
der
e
d
the
i
nf
l
uen
ce
of
wait
in
g
ti
m
e
on
the
util
iz
at
ion
of
t
he
cer
vical
cance
r
screeni
ng
ser
vi
ces.
Th
e
stu
dy
has
est
a
blishe
d
a
di
rect
li
nk
betwee
n
these
two
var
ia
bles
in
that
the
l
onge
r
th
e
wait
ing
ti
m
e
a
t
the
cl
inic,
the
le
ss
the
chance
s
of
util
iz
ing
avail
able
sc
r
eenin
g
ser
vice
s
.
These
fin
dings
are
consi
ste
nt
with
tho
se
f
ro
m
a
qu
al
it
at
ive
stu
dy
do
ne
in
Ma
la
wi
[29]
in
w
hich
t
he
wo
m
e
n
re
porte
d
that
they
wer
e
will
ing
to
be
scree
ne
d;
howe
ve
r,
they
ha
d
not
do
ne
s
o
because
of
the
long
wait
in
g
at
the
cl
inic
.
I
n
ot
her
words,
w
om
en
,
w
ho,
m
os
t
li
ke
ly
,
ha
d
ta
ke
n
tim
e
of
f
from
oth
e
r
r
esp
onsi
bili
ti
es
to
r
ush
to
the
cl
inic,
m
ay
no
t
be
will
ing
to
s
pend
a
lot of
ti
m
e
qu
e
uing
. T
his
sce
nar
i
o
is releva
nt
especi
al
ly
in
the
case
of
scree
ning s
erv
ic
es
whe
re t
he wom
en
li
nin
g
up
would
not
be
e
xp
e
rienci
ng any
releva
nt
heal
th pr
ob
le
m
s.
4.5
.
Ut
il
iz
at
io
n of
c
er
vical
c
an
cer
s
cree
ni
ng
s
e
rvices
This
sect
ion
w
ishes
to
est
abl
ish
w
hether
th
os
e
w
om
en
wh
o
had
pr
e
viously
under
ta
ke
n
a
cerv
ic
al
cancer
test
ha
d retu
rn
e
d f
or
subse
qu
e
nt
te
sts
and the
reas
ons why they
did
so
.
4.5
.1
.
Previ
ous
s
cree
nin
g for
c
ervic
al
c
an
cer
Re
sp
on
den
t
s
wer
e
a
sk
e
d
if
they
ha
d
pr
e
vi
ou
sly
unde
rtak
en
a
ce
rv
ic
al
c
ancer
te
st.
T
he
ir
res
pons
es
are
prese
nted
i
n
Table
18.
Ta
ble
18
capt
ur
es
the
low
upta
ke
of
ce
rv
ic
al
ca
ncer
sc
ree
ning test
a
m
on
g
the stud
y
gro
up.
As
al
re
ady
rec
orde
d
a
bout
the
l
ow
ut
il
iz
at
ion
rate,
o
nly
24.7%
of
t
he
res
ponde
nts
had
previ
ously
been
screene
d f
or
ce
rv
ic
al
ca
ncer.
Table
18
.
P
rev
i
ou
s
Pa
rtic
ipati
on in
Ce
rv
ic
al
Ca
ncer
Scree
ni
ng
Ever been
scr
eene
d
f
o
r
cervical canc
er
Frequ
en
cy
Percentag
e
Yes
71
2
4
.7
No
216
7
5
.3
Total
287
1
0
0
.0
4.5.2.
Cer
vical
c
an
cer
s
cree
n
ing
w
ithin
t
he
l
as
t 3
y
e
ars
The
wo
m
en
w
ho
ha
ve
un
dergone
a
n
init
ia
l
te
st
sh
ould
have
le
arn
t
the
im
portance
of
f
ollow
up
te
sts
.
Hen
ce
,
res
pondents
w
ho
ha
d
pr
evi
ously
te
s
te
d
for
cerv
ic
a
l
cancer
wer
e
aske
d
if
they
had
unde
rtake
n
furthe
r
te
sts
within
the
la
st
three
ye
ars.
Their
res
ponse
s
a
re
as
ind
ic
at
ed
in
Table
19.
As
s
how
n
in
Table
19
, o
f
the 71
respo
nd
e
nts
w
ho
ha
d
eve
r
be
en
sc
ree
ned
f
or
cer
vical
ca
ncer,
a
siz
eabl
e
pro
portio
n,
equ
al
to
88.
7%
,
had
Evaluation Warning : The document was created with Spire.PDF for Python.
IJPHS
IS
S
N: 22
52
-
8806
Factor
s Infl
ue
ncin
g Uti
li
za
ti
on o
f C
ervi
c
al
Can
cer
S
c
reen
ing
Services…
(
Gich
ogo
A
gn
es
Wa
ngechi
)
245
unde
rtake
n
a
s
creeni
ng
withi
n
th
e
past
3
ye
ars
.
T
his
act
io
n
by
the
respo
nd
e
nts
at
te
sts
to
the
posit
ive
ro
le
of
awar
e
ness
, bes
ides
oth
er
f
act
or
s
, in uti
li
zi
ng the sc
reen
i
ng
serv
ic
es
.
Ta
ble
19.
Re
s
ponse
s
on Cer
vical
Cancer
Scre
enin
g W
it
hin
the Last
3 Year
s
Screened
within
th
e last 3
y
ears
Frequ
en
cy
Percentag
e
Yes
63
8
8
.7%
No
8
1
1
.3
Total
71
1
0
0
.0
4.
5.3.
Re
asons
for
u
n
dert
ak
i
ng
s
ubse
quen
t
c
ervical
c
anc
er
scree
nin
g
Re
sp
on
den
ts
who
ha
d
pre
vio
us
ly
been
scr
eened
f
or
ce
r
vi
cal
cancer
we
re
as
ked
t
o
rec
ord
wh
y
t
hey
had
un
der
ta
ke
n
this
subse
quent
init
ia
ti
ve.
Their
res
pons
e
s
are
recor
ded
in
Ta
ble
20.
Table
20
sho
ws
that
m
ajo
rity
(
70.
4
%)
of
the
wom
en
w
ho
had
unde
rgo
ne
ce
r
vical
cance
r
te
st
unde
rto
ok
s
ub
s
eq
ue
nt
te
sti
ng
to
confirm
their
healt
h
sta
tus,
w
hile
ano
t
her
23
.9
%
was
f
ollo
wing
the
d
octo
rs’
a
dv
ic
e.
T
hi
s
again
at
te
sts
to
the
vital
r
ole o
f
aw
aren
es
s
,
an
d
eq
ually
, th
at
of
tho
se in th
e know to
adv
ise
the
w
om
en
to u
ndertake the scr
e
eni
ng
serv
ic
es
.
Table
20.
Re
as
on
s
for U
ndert
akin
g
S
ubse
quent Cer
vical
Cancer
Scr
ee
ni
ng
Reas
o
n
s f
o
r
d
o
in
g
su
b
seq
u
e
n
t cancer
test
Frequ
en
cy
Percentag
e
Needed
to k
n
o
w I
was still h
ealth
y
50
7
0
.4
Had
a
p
rob
le
m
wit
h
m
y
wo
m
b
4
5
.7
W
as
requ
ested
by
a do
cto
r
to
do
so
17
2
3
.9
5.
CONCL
US
I
O
N
In
co
ncl
us
io
n,
we
recor
d
the
key
find
i
ngs
of
the
stud
y:
fin
dings
that
generall
y
con
cu
r
with
si
m
il
ar
stud
ie
s
ar
ound
the
glo
be
.
Th
e
stud
y
has
co
nf
irm
ed
the
ve
ry
low
cer
vical
cancer
util
iz
at
ion
rate
arou
nd
the
globe.
I
n
c
on
tr
ast
to
wh
at
m
i
gh
t
be
ex
pected,
f
or
m
al
edu
c
at
ion
of
the
pa
r
ti
ci
pating
w
ome
n
was
fou
nd
t
o
ha
ve
on
ly
li
m
it
ed
infl
uen
ce
i
n
th
e
util
iz
at
ion
of
avail
able
se
r
vices.
T
his
is
pro
bab
ly
due
to
the
lo
w
le
ve
ls
of
awar
e
ness
on
issues
relat
in
g
to
cer
vical
cancer
scree
ning;
especial
ly
the
m
ist
aken
no
ti
on
of
ce
rv
ic
al
canc
e
r
screeni
ng
as
a
cur
at
ive
r
at
he
r
than
a
preve
nt
ive
m
easur
e.
W
it
h
su
c
h
m
is
ta
ken
no
ti
on
,
un
le
ss
on
e
has
issues
with
he
r
orga
ns,
it
m
ade
l
it
t
le
sense
to
seek
screeni
ng
se
rv
i
ces.
The
stu
dy
has
al
so
est
abli
sh
e
d
the
centra
l
ro
le
of
the
m
al
e
par
tner
in
f
or
m
of
encour
a
gem
ent
and
sup
port,
be
it
finan
ci
al
or
ps
yc
holo
gic
al
.
This
involv
e
m
ent
is
cru
ci
al
par
ti
cularly
in
the
patriarc
hal
so
c
ie
ti
es
wh
ere
m
en
hav
e
a
dom
inant
ro
le
especial
ly
ov
e
r
their
wo
m
en’
s
healt
h
see
king
decisi
on
s
.
S
uc
h
pa
rtner’s
s
uppo
rt
is
eq
ually
i
m
portant
as
t
he
su
bject
in
que
st
ion
involves
a
dise
ase
fou
nd
i
n
th
e
wo
m
an’
s
pri
vate
pa
rts
he
nc
e,
seekin
g
the
screeni
ng
se
r
vices
cou
l
d
le
ad
to
the
m
ist
aken
belie
f
that
the
c
onc
ern
e
d
wo
m
an
has
been
i
nvol
ved
i
n
im
m
or
al
beh
a
vior.
Fin
al
ly
,
the
stud
y
has
est
ablished
tha
t
wo
m
en
are
le
ss
li
kely
to
be
screene
d
for
ce
rv
ic
al
ca
ncer
i
f
,
f
or
w
hateve
r
reason,
wait
in
g
tim
e
at
the
cl
inic
is
le
ng
thy.
Su
c
h
l
ack
of
patie
nce
is
reasonable
for
w
om
en
who
are
forced
t
o
sacrifice
tim
e
from
fam
i
ly
or
jo
b
-
r
el
at
ed
ta
sk
s
;
m
or
e so
,
since
m
os
t
tim
es
the
w
om
en
seekin
g
t
he
se
rv
ic
es h
a
ve
no
ob
vious heal
th
pro
blem
.
The
c
oncl
us
io
n
of
t
his
stu
dy
points
to
thr
e
e
si
m
ple
facts.
First,
ce
rv
ic
al
cance
r
is
easy
to
m
anag
e.
Seco
nd
ly
,
wh
il
e
certai
nly
no
t
belit
tl
ing
the
c
ru
ci
al
healt
h
si
de,
we
nee
d
to
acce
pt
that
the
disease
is
basi
cal
ly
a
so
ci
et
al
probl
e
m
:
and
,
as
w
it
h
al
l
so
ci
et
al
issues,
pr
e
ve
ntion
a
nd
m
anage
m
ent
of
this
di
sease
cannot
be
le
f
t
to
the
co
nce
rned
wo
m
en
a
nd
healt
h
pe
rs
onnel
on
ly
.
It
de
m
and
s
al
l
m
em
ber
s
of
the
s
ociet
y
w
orkin
g
toge
ther
for
the
c
omm
o
n
pu
rpose;
a
nd
as
ex
per
ie
nce
from
al
l
the
world
has
pro
ven
;
s
uc
h
joi
nt
effor
ts
usual
ly
m
eet
their
decla
red
obj
ect
ives
.
It
i
s
with
this
c
onfide
nce
that
th
e
stud
y
offer
s
t
he
f
ollo
wing
r
ecom
m
end
at
io
ns
that
would
e
nsure
conqu
e
st
of
cerv
ic
al
cance
r
am
on
g
w
om
en,
especial
ly
through
en
han
ce
d
a
nd
e
ff
ect
iv
e
util
iz
at
ion
of s
creeni
ng servic
es.
It
is
reco
m
m
e
nd
e
d
that
the
Governm
ent
of
Ke
nya,
thr
ough
the
Mi
nistry
of
Healt
h;
the
ci
vil
so
ci
et
ie
s,
reli
gi
ou
s
an
d
oth
e
r
com
m
un
it
y
gr
oups
;
a
nd
i
nd
i
viduals
of
good
will
,
c
ollaborat
e
in
de
sig
nin
g
a
nd
i
m
ple
m
enting
awar
e
ness
cam
paig
ns
on
cer
vi
cal
cancer;
and
eq
ually
,
the
vital
it
y
of
util
iz
ing
cer
vical
cancer
screeni
ng
ser
vices.
This
s
houl
d
be
done
t
hro
ugh
the
m
edia,
reli
gious
gath
erin
gs
,
wo
m
en
gro
up
s
a
nd
ch
ie
fs
’
bar
azas
(m
eet
i
ng
s
)
a
nd
ot
her
appr
opriat
e
avenues
,
inclu
di
ng
one
-
to
-
one
encou
nters
,
ta
r
geting
both
m
en
an
d
wo
m
en
in t
he
c
omm
un
it
ie
s.
It
is
reco
m
m
e
nd
e
d
that
the
m
en,
especial
ly
the
par
tne
rs,
le
arn
ab
out
cerv
ic
al
cance
r,
especial
ly
the
ro
le
of
the
scre
enin
g
se
rv
ic
es
.
Su
c
h
a
n
e
xposure
sho
uld
le
a
d
to
m
en
giv
in
g
thei
r
wo
m
en
the
need
e
d
spa
ce
i
n
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