i KNOWLEDGE, ATTITUDES AND PREDICTORS OF CERVICAL CANCER SCREENING UPTAKE AMONG WOMEN IN OYO STATE, NIGERIA By Gbonjubola Oludayo OWOLABI MATRIC No.: 92750 RN, RM, B.Sc. Nursing (Ibadan), MSc. (Sociology), MSc. Nursing (Ibadan), A thesis in the Department of SOCIOLOGY Submitted to the Faculty of the Social Sciences in partial fulfilment of the requirements for the degree of DOCTOR OF PHILOSOPHY of the UNIVERSITY OF IBADAN JUNE, 2023 UNIV ERSITY O F I BADAN LI BRARY ii CERTIFICATION I certify that this thesis was carried out by Gbonjubola Oludayo OWOLABI in the Department of Sociology, University of Ibadan, Nigeria. ............................................................................. SUPERVISOR A. S. Jegede B.Sc (Hons), M.Sc (Ife), MHSc (Toronto), PhD (Ibadan) Professor, Department of Sociology, University of Ibadan, Ibadan, Nigeria UNIV ERSITY O F I BADAN LI BRARY iii DEDICATION This work is dedicated to the glory of Almighty God, and in loving memories of my parents: Late Deaconess Caroline Odunola Kolade and Late Pa Samson Ayanrinola Kolade. UNIV ERSITY O F I BADAN LI BRARY iv ACKNOWLEDGEMENTS Firstly, I am grateful to the Almighty, the giver of life, wisdom, grace, and strength. He sustained me throughout my Ph.D. programme – He deserves all the glory. He is the Alpha and the Omega. May His name be praised forever. This programme has truly been a life-changing one for me and it would not have been possible to achieve without the support and guidance that I received from many people. My sincere thanks to Professor Ayodele Jegede, who convinced me during our many discussions in Ibadan, Oyo State to pursue my doctoral degree. I thank him especially as my supervisor, for the unflinching support and the mentoring that I enjoyed throughout the programme. He was so passionately committed to my becoming his ‘mentee’. I thank him for his patience and kindness. I appreciate all my lecturers in the Department of Sociology, especially those that contributed positively to the fulfilment of my post-graduate programmein Sociology. They all impacted on me positively the tenets of sociology that shaped me into a seasoned sociologist. I thank Professors Uche Isiugo-Abanihe, Olanrewaju Olutayo, Olufemi Omololu, Adeyinka A. Aderinto, Bernard Owumi, Rasheed Okunola, Oka Obono, Eze Nwokocha, Ifeanyi Onyeonorou, Emeka E. Okafor, Muyiwa Omobowale and Kabiru K. Salami; DoctorsYinka Akanle, Adebimpe Adenugba, Oludayo Tade, Adefunke Fayehun, Patricia Taiwo, Ayodeji Omo-Lawal, Dauda Busari, and Adekunle Ojedokun, in essence; I appreciate all Post Graduate Coordinators during my course of study who made the process a seamless one for me. I appreciate my senior colleagues and other colleagues I met in the course of my study. I thank Dr. Lukman Fasasi and Dr. Oyebola for their numerous words of encouragement and support throughout the course of my study. This Ph.D. study would have been impossible without the cooperation and support of people from Kishi, Oyo, Ogbomosho, Ibarapa communities and Ibadan. Their patience and sacrifice during the numerous focus group discussions and the household surveys is appreciated. I equally appreciate all the nurses, doctors and the community leaders (Christian, Muslim, and traditional religious leaders) for provision of key information that contributed to the quality of the study. I am grateful for their friendship and the warmth they extended to me during my time in the communities. UNIV ERSITY O F I BADAN LI BRARY v My sincere appreciation goes out to my coursemates, Ronke Adebayo, Mrs. Janet Ogaji nee Ogundairo, Kafayat Aminu, Alj Oluyedun, and all my companions during the study for their support during the period of the data collection, analysis and interpretation. I also appreciate the local field research team members: Sister Bukky, Mummy Ayo, Miss Rita, Dr. Ayo Ogunleke, Mr. Wale Adeoye, Mr. Seun Ipadeola, and the analysts that supported me, Mr. Chris Bamidele, Miss Ayeni, and Mr. Simeon. Their excellent work during data collection and analysis has made an invaluable contribution towards this programme.I appreciate the support, the invaluable advice and the feedback of my mentors. They made the journey an amazing one. I appreciate my daddy, Prof.Olayemi O. Omotade, who supported me from conception till the very end of the study. I also appreciate the Oyo State Government (Late HE Abiola Ajimobi for challenging me to start, and the present HE Seyi Makinde for aiding the acceleration and the completion of the study) for the provision of necessary paraphernalia of office and the successful completion of the study. I especially thank the past Head of Service (HOS) Mr. Soji Eniade who gave the approval to commence the study, and immediate past HOS Mrs. Amidat Ololade Agboola and the current HOS Mrs Olubunmi Olufunke Oni mni for their numerous releases during my study. My gratitude also goes to the Heads of various agencies at the Ministry of Health, Secretariat, Ibadan; Dr. O.A Iyiola, Dr. Olubunmi Ayinde, Dr. Lawal and Dr. Bode Ladipo for their constant support and encouragement. I also appreciate Dr. Muyideen Olatunji, the executive secretary of State Primary Health Care Board for giving express approval to access communities in the selected local government areas. I appreciate all the Principal Officers of Oyo State College of Nursing and Midwifery, Eleyele, Ibadan; the Deputy Provost, Mrs. Iyabo Adeleke; the Registrars(both past and present), Mr. Z. O. Jayeola and Mrs Fatima Yusuf; the Bursar, Ms. Iyabo Bello; the Librarian immediate past and present, Mr. Samuel Awotona and Mr Iseoluwa Adedokun; the Director of Works, Engr. Wale Olawoyin, and the Heads of Departments; Mrs. Ogunniran A. A., and Mrs. M. T. Adeniran, the staff of the College, and the student union government for their constant support throughout the period of this study. I say a big ‘thank you. UNIV ERSITY O F I BADAN LI BRARY vi I sincerely appreciate all my siblings who stood by me during this programme:Revd. Oladele and MrsOmolara Kolade gavetheir spiritual support, and loads of prayer for me;my brother, Prof Oluwaseun Kolade, and his wife, Oreoluwa Kolade, tutored me on how to master the scale of analysis;Revd Drs. Akinwale and Temitope Oloyede gavetheir support throughout the programme, and their invaluable contributions during the period of data analysis is appreciated; Lydia and Abimbola Kolade gavetheir support during the search for relevant literatures.My heartfelt thanks to my family members:my dad (of blessed memory) for always believing in me, and encouraging me to follow my dreams;my children in person of Dasola and Yomi Adedokun, Mr and Barrister Oluwakayode Oluwadara Talabi, Akinkunmi Owolabi, Oluwatunmise, Mojolaoluwa, Moses, and Precious for helping in whatever way they could during this challenging period, and my grandsons, Rereloluwa and Titobiloluwa for being such good babies, and for their chit chats. And finally, to my husband, Pastor Oluwole Owolabi, who has been by my side throughout this programme and without whom, I would not have had the courage to embark on this journey, I want to say I really appreciate his unquantifiable support and I do not take this for granted. UNIV ERSITY O F I BADAN LI BRARY vii ABSTRACT Cervical Cancer (CC), a preventable malignant tumour in women’s cervixes, is one of the most common causes of maternal deaths in developing countries. Despite its preventability through regular Cervical Cancer Screening (CCS), it is the second most common cancer responsible for gynaecological morbidity and mortality in Nigeria. Studies on CC have largely focused on its biomedical contexts, with little attention paid to the social contexts affecting the knowledge and attitudes towards the uptake of Cervical Cancer Screening (CCS). This study, therefore, investigated the awareness, knowledge, attitudes, perceptions of risks, and the socio-cultural factors influencing the uptake of CCS among women in Oyo State, Nigeria. The Health Belief Model was adopted, while the mixed methods, comprising a cross- sectional survey design, was utilised. Oyo State was purposively selected based on the availability of a functional cancer registry. Two Local Government Areas (LGAs) were randomly selected from each of the three senatorial districts. Using Leslie Kish’s (1965) formula, a sample of 960 respondents was determined based on the projected 2019 population of these LGAs. A questionnaire on the socio-economic, attitude, knowledge, perception of the risk factors, and accessibility to screening centres and health workers was systematically administered to women (aged 20-60 years) in the selected LGAs - Oluyole (189), Oyo West (126), Irepo (109), Ogbomosho North (178), Ibarapa-North (91) and Ibadan South-West (267) LGAs. Questionnaire was proportionally administered based on the LGAs’ population. In-depth interviews were conducted with six community leaders, six women and eight religious leaders. Key informant interviews were conducted with four physicians and 12 nurses\midwives. Three focus group discussions were held with married men. The quantitative data was analysed using descriptive statistics, Chi square and multiple regression at p≤0.05, while the qualitative data were content-analysed. The respondents’ age was 34.67±11.91 years, 86.0% earned below ₦45,000 monthly, and 65.3% were married. Awareness of CC was low (38.0%) based on the misconception of its causes, and it varied by income (χ2=14.92), education (χ2=36.77) and employment (χ2=54.87) status. Knowledge about the causes of CC was poor, as 49.3% had knowledge about its symptoms. Socio-cultural factors jointly predicted uptake of CCS (R=0.21, R2 =0.05, Adjusted R2=0.04, (F (4,929) =10.90). Knowledge of CC insignificantly contributed to CCS uptake (β=0.02). Perceived benefit (β=0.54), perceived severity (β=-0.02) and cervical cancer risk perception (β=0.21), independently contributed to the uptake of CCS. More than half (60.0%) had negative attitude towards CCS uptake. Womanhood (62.6%), promiscuity (56.3%), smoking habit (53.7%), and family history (47.0%) were the reported risk factors for CC. A majority of the male discussants associated jejere enu ile- omo with prostitution. The use of herbs, role of diviners, spousal support, and religious beliefs influenced uptake of CCS. The cost of CCS, location of CCS centres, fear of stigmatisation, and perceived pains limited CCS uptake. Poor knowledge and awareness of cervical cancer negatively influenced attitudes towards cervical cancer screening among women in Oyo State, Nigeria. A multi-stakeholder holistic framework to motivate positive awareness and uptake of cervical cancer screening is recommended. Keywords: Cervical cancer screening, Perception of cervical cancer, Risk factors of cervical cancer. Word count:492 UNIV ERSITY O F I BADAN LI BRARY viii TABLE OF CONTENTS CERTIFICATION ........................................................................................................ ii DEDICATION .............................................................................................................. iii ACKNOWLEDGEMENTS ......................................................................................... iv ABSTRACT ................................................................................................................. vii TABLE OF CONTENTS ........................................................................................... viii LIST OF TABLES ...................................................................................................... xii LIST OF FIGURES ................................................................................................... xiv LIST OF ACRONYMS .............................................................................................. xv CHAPTER ONE ........................................................................................................... 1 INTRODUCTION ......................................................................................................... 1 1.1 Background to the study .................................................................................... 1 1.2 Statement of the Problem ................................................................................... 4 1.3 Research questions ............................................................................................. 5 1.4 Objectives of the study ....................................................................................... 5 1.5 Significance of the study .................................................................................... 6 1.6 Scope of the study .............................................................................................. 7 1.7 Definition of concepts ........................................................................................ 7 CHAPTER TWO .......................................................................................................... 9 LITERATURE REVIEW ............................................................................................. 9 2.0 Chapter Overview ............................................................................................ 9 2.1 Conceptual Review ............................................................................................ 9 2.1.1 Overview of Cervical Cancer ......................................................................... 9 2.1.2 Overview of Cervical Cancer Screening ...................................................... 12 2.2 Empirical Review ............................................................................................. 13 2.2.1 Awareness about Cervical Cancer Screening .............................................. 13 2.2.2 Women’s knowledge about cervical cancer screening ................................ 15 2.2.3 Level of Cervical Cancer Screening Uptake among Women ................. 17 2.2.4 Socio-cultural factors, and uptake of cervical screening ........................ 20 2.2.5 Socio-economic factors and uptake of cervical cancer screening ................ 23 UNIV ERSITY O F I BADAN LI BRARY ix 2.2.6 Strategies for promoting cervical cancer screening uptake among women . 25 2.3 Gap in literature .............................................................................................. 27 2.4 Theoretical Framework .................................................................................... 27 2.4.1. The Health Belief Model ............................................................................. 28 CHAPTER THREE .................................................................................................... 35 METHODOLOGY ...................................................................................................... 35 3.0 Chapter Overview ............................................................................................ 35 3.1 Research Design ............................................................................................... 35 3.2 Study area ......................................................................................................... 35 3.3 Population of the Study .................................................................................... 39 3.4 Selection Criteria .............................................................................................. 39 3.4.1 Inclusion criteria ....................................................................................... 39 3.4.2 Exclusion criteria .................................................................................... 39 3.5 Sampling .......................................................................................................... 40 3.5.1 Determination of sample size ....................................................................... 40 3.5.2 Sampling Procedure ..................................................................................... 43 3.5.2.1 Quantitative ............................................................................................... 43 3.5.2.2 Qualitative ................................................................................................ 44 3.6 Research Instruments ....................................................................................... 50 3.7 Study variables ................................................................................................ 53 3.8 Validity of Research Instrument ..................................................................... 56 3.9 Reliability of Research Instrument ................................................................... 56 3.10 Selection and Training of Field Staff ............................................................. 56 3.11 Data Collection Procedure ............................................................................. 57 3.12 Administration of Instrument for Data Collection: Questionnaire ................. 57 3.13 Data Management ........................................................................................... 58 3.14 Methods of Data Analysis ............................................................................... 59 3.14.1 Quantitative Data Analysis ............................................................................ 59 3.14.1.1 Univariate Analysis ............................................................................ 59 3.14.1.2 Bivariate Analysis .............................................................................. 59 UNIV ERSITY O F I BADAN LI BRARY x 3.14.1.3 Multivariate Analysis ......................................................................... 60 3.14.2 Qualitative Data ......................................................................................... 60 3.15 Ethical Considerations .................................................................................... 62 3.16 Limitation of the Study ................................................................................... 63 CHAPTER FOUR ....................................................................................................... 62 RESULTS AND DISCUSSION ................................................................................. 62 4.2 Profile of participants in qualitative interviews .................................................. 66 4.2.1 Awareness of cervical cancer ....................................................................... 67 4.2.2 Sources of information about cervical cancer .............................................. 69 4.3 Knowledge of women about Cervical Cancer ................................................. 76 4.3.1 Knowledge of symptoms of cervical cancer ................................................ 76 4.3.2 Causes of Cervical Cancer ........................................................................... 83 4.3.3 Perceived Risks associated with Cervical Cancer ........................................ 84 4.3.4 Perception about cervical cancer .............................................................. 90 4.3.5 Management, and Prevention of Cervical Cancer ....................................... 92 4.4 Perception of Women about Cervical Cancer Screening ............................. 93 4.4.1 Awareness of Cervical Screening ................................................................ 93 4.4.2 Category of Women Who Go For Cervical Cancer Screening .................... 98 4.4.3 Uptake of Cervical Cancer Screening .......................................................... 98 4.4.4 Factors affecting utilization of cervical cancer screening .......................... 111 4.5 Women’s Attitude towards Cervical Cancer Screening.................................... 114 4.5.1 Women’s attitude towards cervical cancer screening ................................ 114 4.5.2 Women’s attitude in relation to their uptake of cervical cancer screening 116 4.5.3 Women’s attitude to CCS in relation to their knowledge about cervical cancer .................................................................................................................. 118 4.6 Socio-cultural Determinants of Uptake of Cervical Cancer Screening ......... 121 4.7 Accessibility to Facility for Cervical Cancer Screening ................................ 125 4.7.1 Multivariate analysis of the relationship between socio-economic factors 130 4.8. Misconception surrounding awareness of cervical cancer, and screening ....... 138 4.8.1 Cultural factors impinging on uptake of CCS ............................................ 141 4.8.2 Spousal support, and Male Involvement ................................................ 149 UNIV ERSITY O F I BADAN LI BRARY xi 4.9 Discussion of Findings .................................................................................... 150 4.9.1 Theoretical Application .............................................................................. 175 CHAPTER FIVE ....................................................................................................... 177 SUMMARY, CONCLUSION, AND RECOMMENDATIONS ............................ 177 5.1 Summary ........................................................................................................ 177 5.2 Conclusion .................................................................................................... 179 5.3 Recommendations ......................................................................................... 180 5.3.1 Government ........................................................................................... 180 5.3.2 Women .................................................................................................. 181 5.3.3 Religious leaders ................................................................................... 181 5.4 Contributions to knowledge .......................................................................... 181 5.5 Topics for further research ................................................................................ 181 REFERENCES .......................................................................................................... 182 APPENDIX I ............................................................................................................. 194 APPENDIX II ........................................................................................................... 206 APPENDIX III .......................................................................................................... 208 APPENDIX IV ........................................................................................................... 209 APPENDIX V ............................................................................................................ 212 APPENDIX VI ........................................................................................................... 213 APPENDIX VII ......................................................................................................... 214 APPENDIX VIII ....................................................................................................... 216 APPENDIX IX ........................................................................................................... 217 APPENDIX X ............................................................................................................ 218 UNIV ERSITY O F I BADAN LI BRARY xii LIST OF TABLES Table 3.1: Senatorial Districts and Selected Local Government Areas for the Study .. 41 Table 3.2: Quantitative Sample Size Distribution ........................................................ 43 Table 3.3: Multi-stage sampling procedure .................................................................. 46 Table 3.4: Sampling Frame ........................................................................................... 47 Table 3.5: Qualitative Sample Size Distribution .......................................................... 48 Table 3.6: Matrix of Research Instruments for Data Collection Based on Study Objectives ..................................................................................................................... 52 Table 3.7: Problems Matrix - Measurement of Variables ............................................. 54 Table 3.8: Summary of Variable, Definitions and Measurements ................................ 55 Table 3.9: Data Analysis ............................................................................................... 61 Table 4.1 Demographic Characteristics of Respondents .............................................. 63 Table 4.2: Attributes of ID & KI Interviewees ........................................................... 65 Table 4.3: Association between Socio-economic characteristics of respondents and awareness of cervical cancer ......................................................................................... 73 Table 4.4: Knowledge of symptoms of cervical cancer ................................................ 77 Table 4.5: Relationship between awareness of cervical cancer, and knowledge of cervical cancer .............................................................................................................. 81 Table 4.6: Respondent’s perceptions of Risks associated with Cervical Cancer .......... 85 Table 4.7: Association between social-economic characteristics of respondents, and perception of Risks of Cervical Cancer ........................................................................ 87 Table 4.8: Perceptions of Cervical Cancer Screening ................................................... 91 Table 4.9: Association between Socio-economic characteristics of respondents, and awareness of cervical cancer screening ........................................................................ 95 Table 4.10: Association between social economic characteristics of respondents and uptake of cervical cancer screening ............................................................................ 101 Table 4.11: Reasons for non-uptake of cervical cancer screening .............................. 103 Table 4:12: Association between social economic characteristics of respondents, and utilization of cervical cancer screening facilities ........................................................ 112 Table 4.13. Relationship between attitude of respondents to cervical cancer screening, and uptake of Cervical cancer screening .................................................................... 117 Table 4.14. Relationship between attitude of respondents to cervical cancer screening, and knowledge about cervical cancer ......................................................................... 119 Table 4.15: Respondent’s perceptions of Socio-cultural factors affecting uptake of Cervical Cancer Screening .......................................................................................... 122 Table 4.16. Relationship between socio-cultural norms of respondents affecting ..... 124 Table 4.17: Factors affecting utilization of cervical cancer screening ....................... 126 UNIV ERSITY O F I BADAN LI BRARY xiii Table 4:18: Association between social economic characteristics of respondents, and utilisation of cervical cancer screening facilities ........................................................ 127 Table 4.19: Multi linear regression showing the sociocultural factors predicting the uptake of CCS ............................................................................................................. 131 Table 4.20: Multi linear regression showing the knowledge of CC predicting the uptake of CCS ............................................................................................................. 133 Table 4.21: Multi linear regression showing culture predicting the uptake of CCS 135 Table 4.22: Factors influencing uptake of cervical cancer screening ......................... 137 UNIV ERSITY O F I BADAN LI BRARY xiv LIST OF FIGURES Fig. 2.1: Conceptual Schema of Health Belief Model in Uptake of CCS ..................... 32 Fig. 3.1: The Map of Oyo State Showing the Study Areas .......................................... 38 Fig. 3.2: Spatial pattern of administration of questionnaire .......................................... 49 Fig. 4.1: Percentage distribution of awareness of Cervical Cancer .............................. 68 Fig. 4.2: Percentage distribution of major sources of awareness of cervical cancer .... 70 Fig. 4.3: Percentage distribution of knowledge of symptoms of cervical cancer ......... 79 Fig. 4.4: Percentage distribution of awareness of cervical cancer screening ................ 94 Fig. 4.5 Percentage distribution of uptake of cervical cancer screening ....................... 99 Fig. 4.6: Percentage distribution of respondent’s attitude to cervical cancer screening115 UNIV ERSITY O F I BADAN LI BRARY xv LIST OF ACRONYMS ANOVA Analysis of Variance CC Cervical Cancer CCS Cervical Cancer Screening CSC Cancer Screening Centre FGDs Focus Group Discussions FMoH Federal Ministry of Health GPS Geographic Position System HBM Health Belief Model HPV Human Papillomavirus IBCR Ibadan Cancer Registry IDI In-Depth Interviews KII Key Informant Interviews LGAs Local Government Areas MoH Ministry of Health NBS National Bureau of Statistics NGOs Non-Governmental Organizations NPC National Population Commission OCs Oral Contraceptives ODK Open Data Kit RAs Research Assistants SD Senatorial Districts SMoH Social Model of Health SSA Sub-Saharan Africa SSHREC Social Sciences and Humanities Research Ethics Review Committee STDs Sexually Transmitted Diseases STI Sexually Transmitted Infection TFR Total Fertility Rate UCH University College Hospital UN United Nations WHA World Health Assembly WHO World Health Organizations UNIV ERSITY O F I BADAN LI BRARY 1 CHAPTER ONE INTRODUCTION 1.1 Background to the study Cancer is one of the world’smost dreadful diseases in recent decades (World Health Organisation, WHO, 2017). Cancer is characterised by the unrestrained growth and spread of anomalous cells, which wreak havoc on the human body. If improperly managed, cancer may degenerate, break down the body systems and culminate in death (Gakiduo, Nordhagen, and Obermeyer, 2008). There are different types of cancers according to the body parts. Thus, the types are named after the body parts affected. For instance, colon cancer affects the colon, breast cancer affect the breast while cervical cancer affect the cervix. Cancer may not be localised to a specific body part due to the tendency of malignant cells to spread to other areas, with diverse signs. For patients and their loved ones, a cancer diagnosis has life-changing implications including enormous social and economic burdens arising both from the diseased condition and treatment dynamics, which affect and disrupt everyday life. According to WHO (2019), the most common cancers worldwide include cancer of the lung, breast, colorectal, prostate, stomach and non-Hodgkin lymphoma (a type of blood cancer). Although cervical cancer (CC) is not among the common cancers, it constitutes approximately 12% of all cancers in women after breast cancer making it the second most common cancer in women worldwide and the commonest in developing countries (WHO, 2019). Although there is presently no known cure for cancers generally, screening has been recognised as the most effective approach to CC control (Curry, Byers, and Hewitt, 2003; McGraw and Ferrante, 2014). Cervical cancer is not endemic and does not have serious mortality rate in developed countries; since cervical cancer screening (CCS)is adopted by these countries, 65% of mortality rate is cut off. This is at variance in developing countries. According to Frank and Ehiemere (2017), inadequate facilities, materials, and personnel constitute major challenges to CC oncological services. UNIV ERSITY O F I BADAN LI BRARY 2 Cervical cancer can be defined as a malignant neoplasm of the cervix uteri. In developing countries and some other regions like the South and Central America, Sub- Sahara Africa (SSA), South Asia, CC is a major challenge to women’s public health and is the most common type of 1 cancer (Parkin, Forman and Bray, 2014). Cervical cancer as of now is one of the top ten cancers affecting women and the fourth most common cancer globally. There are 1.5 million clinically identified CC cases globally as at 2015 (Ferlay, Soerjomataram, Dikshit, Eser, Mathers, Rebelo, Parkin, Forman and Bray, 2015). Not lesser than 50 million Nigerian women are at risk of CC with an annual CC rate of 14, 089, and an annual mortality of 8240 (Nigeria HPV and Related Cancer Fact Sheets, 2017). Cervical cancer is almost always caused by the Human Papillomavirus (HPV) infection; 23.7% of women harbour this virus worldwide (American Cancer Society, 2016). Mainly, stereotypes 16, and 18 are causative organisms. Many are also spread through sexual relations. In the same vein, wide coverage of screening, and vaccination against CC have been identified as proven methods for drastically reducing both morbidity and mortality, due to the menace in developed countries of the world (McGraw and Ferrante, 2014). About eighty-five percent of mortality due to CC is still domiciled in developing countries like Nigeria (Maine, Hurlburt and Greeson, 2011). The prevalence of CC is primarily influenced by diverse socio-cultural factors (Ferlay et al., 2015). This is one of the impetuses of this study. A resolution of 58.22 was adopted in 2005 by the World Health Assembly (WHA). This resolution urges member states to fight cancer through the creation of National Cancer Control Programmes. Nigeria, with its intent to reduce morbidity and mortality associated with cancer as well as its socio-economic impacts, developed a National Cancer Control Programme in 2008. Embedded on this blueprint is a Cervical Cancer Control Plan established by the Federal Ministry of Health (FMoH). The plan focuses on early detection of CC, and processes for vaccination of young girls between 9-15 years of age to prevent Human Papillomavirus (HPV). However, the level of implementation of this plan has not been effective (Ndikom and Ofi, 2012; Nwobodo and Ba-Break, 2015). Therefore, the effect of this has not yet played out in the reduction of morbidity and mortality rates of cancer in Nigeria. UNIV ERSITY O F I BADAN LI BRARY 3 Several studies on African countries like Uganda, Kenya, Malawi, Tanzania, Egypt and Nigeria have identified poor knowledge of the disease both of which cuts across socio-economic categories. For instance, scholars have reported a low uptake rate of 5.3% across the country as opposed to 75.0% in developed nations (Nwobodo, 2015; Idowu, Olowookere, Fagbemi and Ogunlaja, 2016). In the few cases where women’s awareness and knowledge level about CC are high or on the average, knowledge level seems not to translate into improving screening uptake. Two of the leading determinants of low cervical screening uptake: low disease knowledge levels and inadequate prevention practices, are attributable to health care provision, and policy deficiency (Arulogun and Maxwell, 2012; Nwobodo, 2015). This partly explains why the Federal Government of Nigeria developed a national policy on cancer control plan, and the Oyo State Government followed suit when she launched her policy on April 23, 2018. Additionally, socio-cultural factors significantly influence women’s perception of CC (Nwobodo, 2015). Matsuyana, Grange, Lyckholm, Utsey and Smith (2007) summarized the way culture colours perceptions, communication and information requirements thus playing a key role in providing effective care to ethnically diverse cancer patient. Several studies have attributed the ineffectiveness of CC screening to religious beliefs, low community involvement, lack of spousal support, poor health- seeking behaviour and passivity of opinion leaders (Ntekim, 2012; Modibbo, Dareng, Bamisaye, Jedy-Agba, Adewole, Oyeneyin, Olaniyan and, 2016; Frank and Ehiemere, 2017). Nigeria is a patriarchal society, where male dominance pervades every sphere of the society, including the health-seeking behaviour of women. Similarly, significant others such as mothers-in-law, religious leaders and community leaders may impact screening uptake in socio-culturally defined ways. Unmarried ladies who are vulnerable to CC may not be able to discuss such issues with their parents at the onset of disease, when it could be easily nipped in the bud. Among other cultural factors is the inability of women to freely discuss sexual health issues with their spouses, due to power dynamics, and the sacredness with which such discourse is viewed in Africa. In most of the developing countries, misperception about the disease, stigmatisation and discrimination may also hinder early diagnosis and discourage the screening of women. Like other health problems requiring specialised care, access (availability, UNIV ERSITY O F I BADAN LI BRARY 4 proximity and affordability) to cancer services have enormous socio-economic dynamics (Amzat and Razum, 2014). This is more worrisome in a resource- constrained region like Nigeria. The location of health facilities is urban-based (Jegede, 2010), whereas most women are in rural areas where the majority are poor, with low literacy rates and with low health information, awareness, and knowledge (Nwobodo, 2015). Consequently, the generality of the people is disadvantaged in relation to affordability of screening and treatment of cervical cancer; this translates into low uptake (Modibbo et al., 2021). The aftermath of this low uptake results in women presenting in the late stage of the disease, as well as increased morbidity and mortality of cervical cancer. Therefore, this study investigates the socio-economic and cultural dynamics of CCS uptake. 1.2 Statement of the Problem Cervical cancer remains one of the easily preventable cancers among the myriads of cancers confronting humanity. However, 86.0% of global cervical cases are still domiciled in developing regions like Nigeria, despite the possibility of early detection and prompt treatment achieved already in many developed nations (Olubodun, Balogun, Odeyemi, Odukoya, Ogunyemi, Kanma-Okafor and Osibogun, 2022). Nigeria is yet to achieve a strategically organised, and routine CCS that is accessible and affordable, especially to the vulnerable population. The challenges to treatment and management of diseases are the health seeking behaviour of the people. The health seeking behaviour of the people largely depend on their level of awareness and knowledge of the disease. Most people have wrong perceptions about the causes and cure for CC. This influenced their choice of uptake of cervical screening. Oyo State is a political seat of the old Western Region and a cultural melting pot of the Yoruba people. In effect, this is an archetypical context to interrogate some of the key cultural factors shared by other sub-Saharan African communities, in terms of patriarchy, stereotypes and women’s role and place in society. The people’s perceptions are influenced by the prevailing cultures of the people. The health seeking behaviour of the people is largely influenced by perceptions. The perceptions of the people about CC, risks associated with the diseases, treatment options, benefits of adopting uptake cervical cancer and utilisation of available facilities are often UNIV ERSITY O F I BADAN LI BRARY 5 influenced by the people’s culture. Religion sometimes influences the prescribed treatment methods for diseases, including uptake of CCS. Oyo State currently has four major screening centres that are tertiary institutions, non- governmental organisations, or privately owned facilities. These, of course, cannot be sufficient for the population of women that are at CC risk. The available screening centres are urban-based; whereas the majority of vulnerable women are rural-based and cannot be easily reached. The economic downturn in Nigeria also seriously impinges on the awareness and knowledge of cervical cancer thereby disallowing an improved uptake. Previous studies have focused mainly on perceptions about causes and treatment of CC with little efforts at looking at multi-causal hindrances to adopting Uptake of cervical and utilisation of screening facilities by the people infected with cervical cancer. Previous studies on CC have largely focused on its biomedical contexts with little attention paid to the social contexts affecting the knowledge and attitudes towards the uptake of CCS. This study, therefore, investigated the awareness and knowledge of CCS among women of Oyo State as well as examined the socio-economic and cultural factors influencing the uptake of CCS in the state.To this end, this study considered the following research questions below; 1.3 Research questions i. What is the level of awareness and knowledge of cervical cancer screening among women in Oyo State? ii. What are the socio-economic, and cultural factors that influence the uptake of cervical cancer screening in Oyo State? 1.4 Objectives of the study General objective: The general objective of this study is to assess the level of awareness, knowledge, and socio-cultural factors influencing uptake of cervical cancer screening among women in Oyo State. Specific objectives: The specific objectives are to: a) Assess the awareness of women about cervical cancer; b) determine the knowledge of women about cervical cancer; UNIV ERSITY O F I BADAN LI BRARY 6 c) explorewomen’s perception of risks associated with cervical cancer; d) assess the perception of women about cervical cancer screening; e) examine women’s attitude to uptake of cervical cancer screening; f) identify socio-cultural determinants of women’s uptake of cervical cancer screening; g) identify the socio-economic factors impinging on women’s uptake of cervical cancer screening; h) identify factors influencing utilisation of available facilities for cervical cancer screening. 1.5 Significance of the study A study of this nature is highly significant given the important roles that findings will play in policy formulation and implementation. The findings provide deep contextual insights into the socio-cultural and economic dynamics of CCS uptake. Consequently, the study contributes to the available existing body of knowledge in CC control. Evidence emanating from the study is useful for policymakers on a specific cancer control plan. The study promoted the ideal of health equity while reducing morbidity and mortality, due to CC. The availability of screening, its affordability and appropriate geographical spread of screening centres, both in rural and urban centres, can be more strategically addressed based on the findings of this study. Furthermore, this study explored the significance of demographic and associated social factors such as educational status, occupational status, poverty, positive test result, and lack of knowledge, among others. Understanding socio-cultural determinants of uptake of CCS are important in determining the health seeking behaviour of the people in relations to CC. It helps to also situate the factors that affect the rate of utilisation of available healthcare facilities in the study locations. Findings from this study are significant in determining ways of improving CCS uptake. Also, increase in women’s perception, awareness, and knowledge level will positively influence the overall percentage of women who will access screening. Findings from the study will further facilitate the development of new strategies while consolidating on the existing ones towards the improvement of women’s access to CCS. UNIV ERSITY O F I BADAN LI BRARY 7 1.6 Scope of the study Oyo State was purposively selected for the study because it has one of the oldest cancer registries in Nigeria, established in 1960 at the University College Hospital, Ibadan. The study adopted the existing senatorial districts in the State for a good geographical spread to account for the generalisation of the result of the study. This helps to situate the socio-cultural issues affecting the health seeking behaviour of the people with shared tradition and values. Women within the range of 20-60 years were studied because the incidence of CC is common among this population (American Cancer Society, 2017). Participants for the interviews included, health workers, nurses, and policymakers in the ministry, as resource persons concerned with CCS services.Community opinion leaders, married men and religious leaders across Christianity, Islam, and traditional religions were also selected as participants in key informants’ interviews (KII) and in-depth interviews (IDIs) for this study. Married men were included in the Focus Group Discussion Sessions (FGDs) as the main actors in decision-making in the home which includes health-seeking behaviour. The study did not attempt any bio-medical interrogation; rather the focus was on adoption of social model of health (SMoH) in determining barriers to health care services such as uptake of CCS 1.7 Definition of concepts The following concepts are defined below, as they are used within the context of this study: Cervical cancer: This refers to the malignant neoplasm of the cervix uterine. It is cancer that develops in tissues of the cervix (the organ connecting the uterus, and vagina or neck of the womb). Cervical Cancer is popularly known as “jejereenuile- omo” among the Yoruba people. Socio-economic factors: These are factors that relate to the use of income, wealth, and commodity. Cervical Cancer Screening: is the use of a simple test across a population to identify individuals who have the disease(CC) but do not have symptoms yet. UNIV ERSITY O F I BADAN LI BRARY 8 ScreeningUptake: is the proportion of persons eligible for cervical screening within a population, and has ever been screened. Socio-cultural factors: include a set of concepts, beliefs, customs, practices, structures, myths, perceptions and behaviours that characterise the life of the Yoruba people of Oyo State, Nigeria. Socio-demographic factors: These are factors that relates to the personal characteristics of respondents such as age, gender, religion, place of residence, marital status etc. Socio-economic factors: These are factors that affect financial status of respondents or their families. It includes such factors as education, occupation, work status and income/salary. Knowledge: Knowledge encompasses facts, understanding and insights that an individual possesses about the signs and symptoms of Cervical Cancer and Cervical Cancer Screening. Knowledge is said to be high if the obtainable score is higher than 70%, average if the obtainable score falls in a range of 50%-69% and low if the obtainable score is lower than 50%. Attitude: This refers to an individual’s predisposition or mental state that influences their uptake of cervical cancer screening. The attitude of an individual is said to be positive if the obtainable score is above 50% and an individual’s attitude is negative if the obtainable score is less than 50%. Predictors: These are the variables or features used in making estimates about the uptake of cervical cancer screening. They include the independent variables that are used to predict changes in the dependent variable environment. UNIV ERSITY O F I BADAN LI BRARY 9 CHAPTER TWO LITERATURE REVIEW 2.0 Chapter Overview This chapter reviews the literature related to socio-cultural, and economic factors influencing the uptake of cervical cancer screening from global, national, and local perspectives. The areas reviewed include an overview of CC level of awareness from global, national, and local contexts, knowledge of women aboutCC, level of CCS uptake among women, social, and cultural factors influencing uptake of CCS, and strategies for promoting cervical cancer screening uptake among women. 2.1 Conceptual Review 2.1.1 Overview of Cervical Cancer The uterine cervix connects the uterus to the vagina, which is the uterus's lowest section (womb). Cervical cancer is defined by the United Nations (2016) as a disease that causes abnormal growth in the tissues of the cervix (the opening of the uterus to the vagina) and is caused primarily by the Human Papillomavirus (HPV), a sexually transmitted infection (STI). Early sexual intercourse, taking of birth control pills, and having several sexual partners can all increase the risk of contracting Human Papillomavirus (HPV), which increases the risk of cervical cancer (American Cancer Society, 2016). In addition, women who began sexual activity within a year of their menstrual periods or who have been diagnosed with HPV are likely to develop cervical cancer (Panatto, Amicizia, Trucchi, Casabona, Luigi Lai, Bonanni, Boccalini, Bechini, Tiscione, Zotti, Coppola, Masia, Meloni, Castiglia, Piana, and Gasparini,2012). However, early detection and treatment provide opportunities for preventing cervical cancer which is slow-growing through its progression during precancerous changes. Cervical cancer, a malignant tumour of the cervix uteri, is the fourth most feared cancer in women, and it is growing geometrically. Ferlay et al. (2015) reportthat UNIV ERSITY O F I BADAN LI BRARY 10 528,000 new cases occur globally each year. This is a severe public health worry for women in many low- and middle-income nations in South and Central America, Sub- Saharan Africa, and South and Southeast Asia, where breast cancer is the most common type of cancer among women (Bidwell, Slaney, Withana, Forster, Cao, Loi, and Parker, 2012). According to the American Cancer Society (2016), cervical cancer mortality has decreased by 50% in the previous 40 years, compared to 50-60 years before, when American women died in large numbers from the disease. The use of a device known as a pap smear, which detects alterations in the cervix cells in their precancerous state and also diagnoses cervical cancer in its most treatable state, resulted in a lower death rate. The virus primarily affects women in their forties and fifties, and it is uncommon to encounter a woman under the age of 20 who is infected. More than 15% of affected women are above the age of 65, according to records; nevertheless, those who are examined on a regular basis are always found to be healthy (American Cancer Society, 2016). Cervical cancer stemmed from persistent infection with the Human Papillomavirus (HPV) in more than 70% of cases (American Cancer Society, 2016). When compared to other types of cancer, cervical cancer can be avoided. The major method of preventing cervical cancer is to eradicate the Human Papillomavirus (HPV), a sexually transmitted infection that causes the disease; this will help to reduce cancer related mortality. HPV infection is more difficult to prevent in the first place than most other sexually transmitted illnesses. Infected women with the human papillomavirus are usually asymptomatic. HPV is easily transferred, and there are no cures for the underlying illness (Akpo, Deji, Idiake, Otohinoyi and Medavarapu, 2016). Cervical cancer incidence in the United States of America follows this pattern, with Hispanics, African-Americans, Asians, Pacific Islanders, and Whites having the highest risk, while American Indians and Alaskan natives had the lowest risk (American Cancer Society, 2018). Invasive cervical cancer was detected in 12,820 new cases in 2017, with 4,210 deaths (American Cancer Society, 2018). Every year, 3,224 new instances of CC are diagnosed in the United Kingdom, with 890 deaths. Cervical cancer affects women all over the world, but the highest rates of incidence and mortality are seen in Eastern, Western, and Southern Africa, as well as South- UNIV ERSITY O F I BADAN LI BRARY 11 central Asia and South America. Despite the threat that cancer poses to public health in Sub-Saharan Africa (SSA), few countries in the region have processed data on cancer incidence. The majority of modern cancer incidence data in SSA is based on reports. Despite the challenges of cancer registration in underdeveloped countries, these cancer records offices have steadily produced incidence statistics for the previous 10–20 years. According to Jedy-Agba, Curado, Ogunbiyi, Oga, Fabowale, Igbinoba, Osubor, Otu, Kumai, Koechlin, Osinubi, Dakum, Blattner, and Adebamowo (2012), Malawi has the highest prevalence of cervical cancer by age-standardised rate of 75.9, followed by Mozambique with 65.0, Comoros with 61.3, and Zambia with 5. In the same vein, Uganda, Mali, and Nigeria each had 44.4, 41.2, a 29.0 respectively. Cervical cancer is also the second most common malignancy among women aged 15 to 44 in Uganda, Mali, Nigeria, and Zimbabwe. According to Jemal, Bray, Center, Ferlay, Ward, and Forman (2011), the majority of women (60-75%) who live in rural areas, where there is inequality or a lack of access to health care, are the most affected by this cancer at a time in their lives when their contributions are most needed in the family and community. In Nigeria, a similar study is being conducted since around 50 million women are at risk of developing cervical cancer. According to Abiodun, O. A., Olu-Abiodun, O. O., Sotunsa, J. O. and Oluwole, F. A., 2014, 14,089 women are diagnosed with cervical cancer each year, with 8,240 dying as a result of the disease. Cervical cancer is the main cause of death among women in poor nations, according to Ndejjo, R., Mukama, T., Musabyimana, A. and Musoke, D. (2016), with 86 percent of cervical cancer deaths occurring in developing countries each year. In Nigeria, the use of cervical cancer screening for the prevention of the illness is still low. The low figure of women who use screening services, despite its presence in a colposcopy facility of University College Hospital, Ibadan's antenatal clinic, is supported by Arulogun and Maxwell (2012). It was documented that between 2005 and 2007, only 3,038 women were screened out of the vast number of women who visited the antenatal clinic and the hospital as a whole. Therefore, CCS should ideally be a standard part of a woman's health care since it can detect cancer or abnormalities that may progress to cervical cancer. As a result, routine Pap smear screening can considerably lower cervical UNIV ERSITY O F I BADAN LI BRARY 12 cancer mortality risks (Ebu, Mupepi, Siakwa, and Sampselle, 2015). Cervical cancer is avoidable, according to Ndejjo et al. (2016), and good screening programmescan minimize morbidity and mortality rates. 2.1.2 Overview of Cervical Cancer Screening Cervical cancer screening is a vital component of women's healthcare aimed at detecting precancerous changes or early-stage cervical cancer. Screening programmeshelp identify women at risk so that appropriate interventions can be implemented to prevent the development of invasive cervical cancer. The availability and implementation of screening programmesvary across countries and regions, influenced by factors such as healthcare infrastructure, resources, and national policies. Screening for cervical cancer is crucial because symptoms often do not appear until the disease has advanced. Detecting pre-invasive lesions or precancerous lesions early can lead to a near 100% five-year survival rate. Current treatment methods can effectively cure these lesions. In the absence of screening, a significant number of cervical cancer cases in India are diagnosed in advanced stages (III and IV). Without timely intervention, the 5-year relative survival rate for cervical cancer is approximately 50%, and nearly 20% of women with cervical cancer die within the first year of diagnosis. (Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM). The goal of screening for cervical cancer is to find precancerous cervical cell changes, when treatment can prevent cervical cancer from developing. Sometimes, cancer is found during cervical screening. Cervical cancer found at an early stage is usually easier to treat. By the time symptoms appear, cervical cancer may have begun to spread, making treatment more difficult. Prognosis can be improved if screening is embraced and widely employed. For this, it is important that the healthcare workers are educated and well aware so that they can influence the beliefs and actions of the general public. Many studies have been conducted in other developing countries to assess the knowledge and awareness about cervical cancer and to study the extent of utilization of the screening methods (Jassim, G., Obeid, A. and Al-Nasheet, A., 2018). UNIV ERSITY O F I BADAN LI BRARY 13 2.2 Empirical Review 2.2.1 Awareness about Cervical Cancer Screening Cancer of the cervix is the leading cause of cancer-related death in developing countries (Palikhe, B., and Pokhrel, S., 2022). Nigeria, India, China, Brazil, and Bangladesh represent over 50% of the global burden of cervical cancer deaths (Cervical Cancer Fee Coalition), Therefore, cervical cancer screening is a vital component of women's healthcare aimed at detecting precancerous changes or early- stage cervical cancer. Screening programmes help identify women at risk so that appropriate interventions can be implemented to prevent the development of invasive cervical cancer. The availability and implementation of screening programmesvary across countries and regions, influenced by factors such as healthcare infrastructure, resources, and national policies. Developed nations havebeen able to implement HPV-based organized screening programmes(eg, Australia, the United Kingdom, and the Netherlands) including the use of self-sampling as a collection option which hasgreatly controlled the surge of cervical cancer(Maver, P. J., and Poljak, M., 2020). In a study by Caird, H., Simkin, J., Smith, L., Van Niekerk, D., and Ogilvie, G. (2022), it was reported that for more than 50 years, the Pap smear test has been used to routinely screen women in Canada for cervical cancer. The majority of Canadian jurisdictions have established screening programmes, and each province and territory has recommendations that urge screening starting at age 21 or 25 every one to three years, Caird et. al, 2022 further stated. Poor cervical cancer screening awareness in Canada has been noted as a major deterrent to screening in groups including immigrant women and communities of ethnic minorities. Recent systematic reviews have revealed certain attitudes and beliefs regarding HPV testing as both impediments and enablers of HPV test acceptance. High perceived advantages of the HPV test, for instance, were linked to higher acceptance of the test, but negative emotions (such as embarrassment associated with testing for a STI) were linked to reduced acceptability of the test (Tatar, O., Thompson, E., Naz, A., Perez, S., Shapiro, G. K., Wade, K., and Rosberger, Z., 2018). Poor understanding about cervical cancer screening was a recurring concern in all focus group discussions in a qualitative research including women from two Serbian UNIV ERSITY O F I BADAN LI BRARY 14 cities (Markovic, M., Kesic, V., Topic, L., and Matejic, B., 2005). In contrast, most of the respondents in a research conducted in rural areas of Eastern Uganda recognized that cervical cancer could be avoided and they could name at least one effective preventive intervention. The greater awareness of cervical cancer prevention in the Ugandan research may be due to stronger media efforts there, since the majority of study participants learned about the disease via radio as reported by Mukama, T., Ndejjo, R., Musabyimana, A., Halage, A. A., and Musoke, D., 2017). Due to the implementation of the national cervical screening programme in 1988, the incidence of cervical cancer reduced from 22 to 13 per 100,000 people in England between 1972 and 2012 but in Australia, the incidence and mortality were reported to be 10 and 2 per 100,000 people in 2015 as reported by (Fabiano, G., Marcellusi, A., Mennini, F. S., Sciattella, P., and Favato, G., 2023). Additionally, it has been observed that referrals for cervical cancer screening and orientation during gynaecological appointments greatly increase screening uptake. Uptake of cervical cancer screening differs significantly according to the developmental stride of individual countries. To remove these obstacles, the health system must be equipped to execute swiftly implemented clear policies and procedures. Gender equality, as well as the development of women's and girls' health and rights, should be supported by the policies. In order to successfully address the unequal burden of cervical cancer in Low middle income countries LMICs, community-wide information distribution, engagement and advocacy, as well as focused additional research on obstacles to care across varied populations and circumstances, are required. The goals of the WHO's worldwide plan to eradicate cervical cancer as a public health concern will only be achieved by lowering the barriers to cervical cancer screening that so many women still encounter (Petersen, Z., Jaca, A., Ginindza, T. G., Maseko, G., Takatshana, S., Ndlovu, P., and Moyo, S., 2022). Stopping the progression from pre-cancer to invasive cancer is the aim of cervical cancer screening to reduce the incidence and death linked to cervical cancer. HPV tests, Pap smears, cytology, and visual inspection with acetic acid (VIA) are the suggested screening procedures (World health organization, 2014). According to the results of a 2012 World Health Organization study, the "see and treat" or "single visit" VIA and cryotherapy technique is a workable and efficient strategy that may be used UNIV ERSITY O F I BADAN LI BRARY 15 in low-resource situations like Nigeria. It may be used at a basic healthcare centre and ensures treatment adherence soon after diagnosis. Some North African nations, including Morocco, which had 3,388 new cases and 2,465 fatalities in 2019 compared to the 12,075 new cases, have adopted this strategy as posited by Safaeian, F., Ghaemimood, S., El-Khatib, Z., Enayati, S., Mirkazemi, R., and Reeder, B., 2021. If cervical cancer is to be eradicated every country should achieve the 90-70-90 targets by 2030 according to the Global Strategy for Cervical Cancer Elimination adopted in 2020 by the World Health Assembly or better explainedas "90% of girls fully vaccinated with the HPV vaccine by the age of 15, 70% of women screened using a high-performance test by the age of 35, and again by the age of 45, 90% of women with pre-cancer treated, and 90% of women with invasive cancer managed" (Olubodun et al., 2022). Prognosis can be improved upon if screening is embraced and widely employed. For this, it is important that the healthcare workers are educated and well aware so that they can influence the beliefs and actions of the general public (Jassim et al., 2018). 2.2.2 Women’s knowledge about cervical cancer screening Women who are most affected by cervical cancer need to be well-informed about the disease's incidence, prevention, and treatment. The Human Papillomavirus (HPV) is the most rampant virus infecting the female reproductive tract, and it is the leading cause of cervical cancer in people that engage in sex actively. Because of the risk of re-infection, HPV is one of the most difficult sexually transmitted infections for women. Cervical cancer is one of the most preventable types of cancer in women. Lack of knowledge about the disease and its risk factors, perceptions about the disease, and poor access to preventive services all influence the decision to be screened. The American Cancer Society classified smoking and long-term use of oral contraceptives (OCs) as risk factors for cervical cancer in 2018. Aweke, Ayanto, and Ersado (2017) discovered that 46.3 percent of the people in their research population had a poor perception of cervical cancer. In the study population, a lack of knowledge is linked to a lack of positive views. According to studies by Nwabichie, Manaf, and Ismail (2018), citing Ferlayet al. (2012), the top 20 countries with the highest UNIV ERSITY O F I BADAN LI BRARY 16 incidence of cervical cancer in 2012 were Malawi (75.9%), Mozambique (65.0%), Comoros (61.3%), Zambia (58%), Zimbabwe (49.3%), Bolivia (49.7%), Guyana (46.9%), Madagascar (44.6%), and Uganda (44.6%). According to Sowemimo, Ojo and Fasubaa’s (2017) report, CC rates in Nigeria are concerning, and if significant gains are to be made in the future, efforts must be made to scale-up screening facilities in all parts of the country. A far-reaching nationwide cervical cancer screening programmewith an objective of covering more than (80%) of the population at risk would be the most effective way to achieve this. In April 2018, the Federal Government of Nigeria launched a nationwide plan to combat cervical cancer, and the state government of Oyo followed suit by launching its own on (April 23rd, 2018). The public's and healthcare practitioners' education about cervical cancer, its risk factors, and prevention techniques is critical to the disease's control. This will go a long way toward enhancing screening uptake and, if appropriate, adherence to treatment recommendations. In Nigeria, incorporating a single-visit screening and treatment technique into routine primary health care services will ensure that underserved groups are reached. This will ensure that services are decentralized and that rural-urban coverage is ideal. According to Ndikom, Ofi, and Omokhodion (2014), young women in Nigeria are uninformed of their vulnerability to cervical cancer, therefore roughly half of them are sexually exposed early in life. While studying female undergraduates in Ibadan, the authors concluded that sexual exposure and experience were common among young women under the age of 20. Before that time, 51.7 percent of the study group had been exposed to sex. This puts them at higher risk, particularly if no precautions are taken. Several studies have identified poor, inadequate, or insufficient understanding as a barrier to screening adoption. Sawadogo, Le Douaron, Maciuk, Bories, Loiseau, Figadère, Guissou, Nacoulma (2012) discovered inadequate knowledge in the study population in Burkina Faso and Zimbabwe, which is verified by Sawadogo et al. (2012) in Burkina Faso and Zimbabwe. According to Jia, Li, Yang, Zhou, Xiang, Hu, Zhang, Chen Ma, and Feng (2013), proper understanding about cervical cancer can reduce anxiety and stigma associated with screenings, resulting in increased UNIV ERSITY O F I BADAN LI BRARY 17 participation. Women's knowledge of the disease is influenced by socio-demographic characteristics and access to health care, according to Aweke et al. (2017). According to Geremew, Gelagay and Azale (2018), women's strong understanding of CC and screening is linked to screening uptake. As a result, pre-cancerous lesions can be identified before they progress to the malignant stage, lowering disease death rates. In a study conducted in Ethiopia, women's educational level is associated to their understanding about cervical cancer (Mitiku and Tefera, 2016). In a similar vein, Ahmed, Sabitu, Idris and Ahmad (2013) found that general knowledge of cervical cancer screening was good, while attitudes were fair; however, this did not translate to good practice in their study in Northern Nigeria. Abiodun, Fatungase, Olu-Abiodun, Idowu-Ajiboye, and Awosile, J. O. (2013)made a similar claim with other researchers, with the exception that when participants appear educated, their knowledge level increases to moderate or high, albeit further research is needed to establish if knowledge translates to practice. As Mthepheya and Chepuka (2017) noted, more than three-quarters of respondentshad no knowledge of the signs and symptoms of CC. This is by implication suggesting that the knowledge of women about CC is quite low. Even when knowledge is readily available, it may not always translate into excellent behaviours. However, this study assesses the level of women's knowledge of CC in Oyo State for this reason. According to Zahedi, Martius and Ay (2013), expertise is inadequate even among healthcare workers in simple, cost-effective "screen-and-treat" programmesthat might have a significant impact on the population's general health; thus, health workers must be trained and retrained. According to Jassim et al. (2018), the religious and traditional aspects of culture are a barrier to approaching a male doctor; also, society frowns on unmarried women seeking reproductive care, such as screening. Promiscuity, according to some, is what motivates women to seek CCS. 2.2.3 Level of Cervical Cancer Screening Uptake among Women Cervical screening uptake is influenced by a variety of factors. According to Population Services International (2016), evidence from a variety of contexts suggests that a number of characteristics are linked to a higher likelihood of being screened for cervical cancer. Higher levels of education, older age, and higher income, greater UNIV ERSITY O F I BADAN LI BRARY 18 parity, and knowing someone who has been screened or diagnosed with CC are all examples. Previous studies have also highlighted the links between low risk of CC and screening, according to Rasul, Cheraghi, and Moqadam(2015). The study's participants emphasized their physicians' and healthcare providers' decision to access or not access screening. The role the doctors played in uptake, and non-uptake is significant. For example, a participant’s verbatim report goes thus: Our health care system does not push us or force us to go, and have a Pap smear. For instance, if I have a gynecology problem, I go to a gynecologist. However, my doctor never asks if I have had a check-up. She never tells me that it is good to do this test. She would never ask this question to encourage us to come, and have the test (Rasul et al., 2015, p. 23). The poor involvement rates of women in cervical cancer screening programmeshave been attributed to the following reasons: lack of information and awareness of cervical cancer, which are the most common barriers to cervical cancer screening programmes. Other obstacles include a lack of financial means, a long commute to a health institution, and significant wait times for a Pap test appointment. Cervical cancer screening, on the other hand, is linked to a higher education level and a white-collar work. Furthermore, screening experiences are highly and positively connected with health insurance coverage and access to knowledge through education and the media.Tiruneh, De Cock, Spector and Elen (2017) also identified certain variables that contribute to women's low engagement in cervical cancer screening programmes, including a lack of education and awareness about the disease. Higher education, meaningful employment, health insurance coverage, access to information through education, and media are all favourable aspects that can help with screening. The autonomy and decision-making of women when it comes to cervical cancer screening are equally crucial. Gender norms and values, gender challenges, women empowerment, and other important subjects. Women's mobility and decision making are influenced by norms and values, as well as access to and use of sexual reproductive health care. Low level autonomy of women in the community can influence cervical cancer screening through cultural ideas and practices. Most cultural norms place a high priority on autonomy, which will obstruct women's access to cervical cancer screening and treatment, as well as their health-seeking behaviour. UNIV ERSITY O F I BADAN LI BRARY 19 In their submission, Tiruneh et al. (2017) stated that if women's levels of awareness are to be positively influenced, policymakers and health care providers must consider all of these barriers. Gender norms and values continue to have great impact on access to and utilization of sexual reproductive health treatments in most developing countries, according to Corroon, Speizer, Fotso, Akiode, Saad, Calhoun and Irani (2014). Gender norms may have an impact on women's mobility and decision-making authority when it comes to health care. Women's empowerment in the context of their household, as well as their relationships with their partners, can have a significant impact on their use of reproductive health services. Women's low autonomy can influence CCS at the community level through cultural ideas and behaviours. Most cultures regard women seeking health care outside their homes to be inappropriate, especially in rural areas, where women are not expected to visit health care facilities alone; these women are less likely to use reproductive health care services. Men's perceived unwillingness to participate in women's reproductive health issues is based on cultural and economic factors; otherwise, if properly informed, they can be eager collaborators. Spousal participation is a major factor of screening uptake in these areas in this case. Cervical cancer screening is expected to be routine, thus policymakers and healthcare planners should bolster women's trust in present health- care units that provide other reproductive health-care services like prenatal, postnatal, and family planning. These units serve as the screening entry point (Mutyaba, Faxelid, Mirembe, and Weiderpass, 2007). Not being aware of cervical cancer screening services, health facility-related challenges such as distance to health facilities and costs of the service, and individual perceptions related to; having no signs and symptoms of the disease, not being at risk, lack of time, and fear of test outcomes were all identified as barriers to screening by Ndejjo et al. (2016). According to Idowu et al. (2016), despite the fact that screening is a well-known and cost-effective technique for lowering the global burden of cervical cancer, its acceptance, particularly in developing countries, is still poor. One of the barriers to access has been that most cervical cancer screening services in Nigeria (offered by both government and non-government organizations) have been inconsistent and poorly organized. The bulk of services are provided in cities; rural and semi-urban residents are often overlooked. Another issue is women's lack of knowledge about UNIV ERSITY O F I BADAN LI BRARY 20 cervix cancer and cervical cancer screening, as well as late presentation at advanced stages when the prognosis is bad. They also stated that screening services are largely accessible in government-owned tertiary and secondary health facilities, with assistance from a few non-governmental organizations. The exorbitant cost of screening, which can reach up to nine thousand naira (25 USD) adds to an already precarious situation, especially in a nation like Nigeria where the majority of people live in poverty and the healthcare system is heavily reliant on out-of-pocket expenditure. According to Frank and Ehiemere (2017), lack of necessary screening facilities, reagents, and equipment in various clinical settings; non-availability of female health care providers; lack of adequate skills required by health care providers; believing oneself not to be at risk of developing cervical cancer, fear of cancer detection, pain, embarrassment, poverty, and economic reasons; the generally poor attitude toward preventive health measures; and the fact that some religious and cultural groups do not discuss sex and sexual organs publicly because they believe their cultural and religious values are being endangered. Poor education is one of the barriers to screening; women with less education were less likely to participate in screening.Also, the relationship between education and participation demonstrates the difficulties that women with less education have in understanding the benefits of cervical cancer screening (CCS). Education influences screening behaviour through its effect on income and its link with individual knowledge about cancer screening, according to previous study on the relationship between socioeconomic characteristics and the use of health services. 2.2.4 Socio-cultural factors, and uptake of cervical screening In the last two decades, scholars all over the world have stated that socio-cultural factors, as well as intrapersonal, interpersonal, organizational community, and social issues, are barriers to cervical cancer awareness (Goodman, 2013). Despite the availability of screening programmesand cancer treatment facilities, some women refuse to use them, according to Goodman's extensive study of the social ecology of cervical cancer in affluent countries. According to the study, there are several social and cultural explanations behind this. Earlier investigations from several nations have come up with nearly identical conclusions. UNIV ERSITY O F I BADAN LI BRARY 21 According to Leinonen, Schee, Jonassen, Lie, Nystrand, Rangberg, Furre, Johansson, Tropé, Sjborg, Castle and Nygrd (2017), a number of demographic, psychological, and social factors influence whether or not to attend a screening. Even among people who have a positive attitude about screening, practical obstacles can still prevent them from attending. Traditional Zimbabwean churches, according to Mutambara, Mutandwa, Mahapa, Chirasha, Nkiwane and Shangahaidonhi (2017), discourage women from obtaining medical help, urging them to have faith and let God heal them. Traditional churches (Apostolic Churches) have an indigenous origin, with local Zimbabwean founders; as a result, their practices are quite similar to traditional cultural practices. The majority of these churches forbid their adherents from seeking medical help. These Apostolic churches place a strong emphasis on faith healing and strict obedience to church teachings and practices, all of which are detrimental to modern health treatment. Community-level factors influence cervical cancer screening behaviour, according to Tiruneh et al (2017). The geographical distribution of medical resources, media exposure to health information, career possibilities, health insurance coverage, and women's sexual autonomy as well as community education, all have a role in their screening behaviour. However, community involvement provides motivation for both access to screening and strategies to increase screening uptake. Community involvement, spousal involvement, and user centre initiatives have all been shown to improve cervical cancer screening uptake in a few studies (Adegboyega, Aleshire, Dignan and Hatcher, 2019). Furthermore, cervical cancer is common between the ages of 40 and 55 in women who are already susceptible to high parity and who live in a poor rural community or, worse yet, a camp for internally displaced people, especially in these days of terrorism, making the subject matter one that should be prioritized (Ndikom et al., 2012; Nwobodo, 2017). Women with learning difficulties have lower rates of cervical cancer screening in the United Kingdom. In Italy, higher levels of cervical cancer screening were connected with education and occupation as compared to jobless women (Damiani, Federico, Basso, Ronconi, Bianchi, Anzellotti, and Ricciardi 2012). Education was recognized as a key component among the socio-demographic and reproductive drivers of CC in low-resource settings by Konathala, Mandarapu and Godi (2017). In India, increased UNIV ERSITY O F I BADAN LI BRARY 22 public awareness, improved living circumstances, and the installation of a CCSprogramme have all contributed to a remarkable reduction in the high prevalence of cervical cancer in slum regions. This strategy could be implemented in Nigeria as well. The occupation was the next most important factor in determining whether or not cervical cancer screening services were available. Previous research indicated that occupation had a substantial impact on cervical screening knowledge(Konathala, Mandarapu, Sanapala, and Godi, 2017). Early coital debut, early marriage before age 20, a large number of pregnancies, unprotected sex, multiple sex partners, partners with other concurrent partners, sexually transmitted infections, use of oral contraceptives, the successive incidence of cervical cancer within the family, smoking, and immunosuppressant including human immunodeficiency virus (HIV) infection were all identified as risk factors for cervical cancer. According to Odaibo, Nejo, and Olaleye (2018), most Nigerian women have high risk factors for cervical cancer, such as high rates of sexually transmitted infections like HPV, early initiation of sexual activities, high parity, and inconsistent condom use. As a result, increasing cervical cancer screening procedures among these high-risk women is critical. According to Onyenwenyi and Mchunu (2018), healthy women in rural areas do not see the need for hospital check-ups. When there are obvious symptoms and herbal remedies have failed to provide the desired results, it is necessary to seek hospital care. As a result of this behaviour, late presentation occurs. Anxiety about the results being revealed, as well as a lack of awareness, are barriers to screening uptake, according to Modibbo et al. (2016). In her study, Ebu (2015) found that women who are uneducated are less likely to use health services because of misconceptions and personal opinions about them. Men's perceived unwillingness to assist in women's reproductive health issues is based on cultural and economic factors; otherwise, they are potentially willing collaborators if properly informed (Mutyaba et al., 2007; Blackstone and Iwelunmor, 2017). Researchers have been unable to pinpoint why screening uptake is poor, despite the presence of other factors such as high awareness, a strong knowledge base, free screening services, and well-organized screening programmes. If CCS uptake will improve in the community and globally, the role of UNIV ERSITY O F I BADAN LI BRARY 23 social and cultural factors is critical. The goal of the study is to see how socio-cultural factors influence cervical cancer screening uptake. Cervical cancer and screening primarily impact women, making it a gender problem. The involvement of husbands as significant decision makers in terms of household income, the role of other family members such as the mother-in-law, and the decision on which health facility the family will utilize cannot be disregarded. In an East African study, it was discovered that men's knowledge of cervical cancer influences women's uptake of screening, since the results show that men with greater levels of education had a higher degree of awareness (Rosser, Zakaras, Hamisi, and Huchko, 2014). In a similar line, a study conducted in Makarfi, Borno State, found that men functioning as screeners has an effect on women's screening uptake because women are discouraged from attending clinics when men serve as screeners (Akintola, Odutola, Olayinka, Akinjiola, Nwokwu and Adebamowo, 2021). Male dominance was also found to have a negative impact on cervical cancer screening uptake in a study conducted by Ojiyi and Dike (2008) at Imo State University Teaching Hospital, Orlu, Nigeria.Among 450 women randomly selected from various clinics, the majority of the respondents stated that if they were to get a pap smear they would rather have it done by a female doctor. Anyebe, Opaluma, Maktarr, and Phillip (2014) found that the fear of exposing private parts to male doctors was a major cause for the lack of screenings among nurses at Ahmadu Bello University Hospital in Zaria, Kaduna State, Nigeria. This is in line with Mthepheya and Chepuka (2017), who assertedthat the gender of the screening personnel is also a factor that influences women's use of screening services. According to a study conducted by Mthepheya and Chepuka (2017), married males in Phalombe are unaware about cervical cancer and screening, even if they are aware of the condition. Their awareness, however, constitute a threat to women's access to cervical cancer screening. It has been proven that these findings may be obtainablein all parts of Africa. 2.2.5 Socio-economic factors and uptake of cervical cancer screening Considering the fact that cervical cancer is commonly referred to asa disease of poverty, and poor women are more likely to have it as low socioeconomic UNIV ERSITY O F I BADAN LI BRARY 24 circumstances are a risk factor for getting it (Goodman, 2013). Similarly, a link between HPV infection, poverty, high parity, and poor sanitary conditions was identified as a co-factor for cervical cancer in a study in Mali (Palacio-Mejia, Range- Gomez, Hernandez-Avila and Lazcano-Ponce, 2003). Trebatická, J., Kopasová, S., Hradečná, Z., Činovský, K., Škodáček, I., Šuba, J. and Ďuračková, Z. (2006) found that wars, political instability, internal conflicts, natural catastrophes, starvation, and drought all contribute to unsatisfactory living conditions in Sub-Saharan Africa. For a long time, these frequently result in both internal and exterior displacement. The author cited the Vietnam War as an example, as well as the American Cervical Cancer Prevention Project. Rapes, prostitution, multiple marriages, and cohabitation are among social vices that enhance HPV spread. According to Gakidon et al. (2008), CCS in 57 countries revealed that just 19 percent of women in developing countries have access to screening, compared to 73 percent in industrialized ones. Countries like Brazil had coverage of up to 80%, whereas Bangladesh, Ethiopia, and Myanmar only had coverage of 1% or less. Other academics have recognized some of the underlying socio-economic causes. In their research of socio-economic disparities among Korean women between 1998 and 2010, Lee, Park, Chang, Kwon, Yoo and Kim (2013) discovered that uptake increased from 40% to 52.5 percent, with significant increases in household income and educational level. In a similar vein, Rohani-Rasaf, Rohani-Rasaf, Asadi-Lari and Hashemi Nazari (2018) reported on a similar study in Iran. Iran Cancer Registry Data revealed the similar pattern of socioeconomic class for cervical cancer. This is also in line with the findings of Arrossi, Ramos, Paolino and Sankaranarayanan (2008), who found a link between women's income and access to screening services in Argentina, resulting in increased uptake. Giswab, El-Khatib, Wolancho, Amdissa, Bamboro, Tadesse Boltena, Appiah, Asamoah, Wasihun & Tareke (2022) assessed the uptake of cervical cancer screening and its predictors among women of reproductive age in Gomma district, South West Ethiopia. The study found that Women’s marital status, residence, occupation, distance to primary health care facility, health workers encouragement, frequency of health facility visits, birth experience, place of birth, awareness about cervical cancer and cervical cancer screening service were the predictive variables of reproductive age UNIV ERSITY O F I BADAN LI BRARY 25 women’s uptake of the cervical cancer. This is in close corroboration with the study by Broberg, Wang, Östberg, Adolfsson, Nemes, Sparén, and Strander (2018), where it was identified that factors such as country of residence, income, being in the labour force, country of birth, education, living with a partner, and receiving welfare benefits were all independently related to non-attendance in cervical screening. Previous studies have also found that attendance in screening is lower among older women, women with low socio-economic status, including a low education level,and women with low use of health care (Seidel, Becker, Rohrmann, Nimptsch, Linseisen, 2009). From the above studies, it can be concludedthat uptake of cervical cancer screening and practices is low. This calls for the need to conduct continuous intervention programmes by health care providers to develop health seeking behaviour towards the uptake of cervical cancer screening. 2.2.6 Strategies for promoting cervical cancer screening uptake among women The government, non-governmental organizations(NGOs), communities, religious organizations, health personnel, family members, and corporate organizations must intensify efforts towardscreatingintervention programmes. Such intervention programmes should come with the understanding that cervical cancer is a threat that must be addressed head on.The developing world must, therefore, develop policies that will improve adequate awareness, perception, and uptake of cervical cancer screening by women. According to Chirwa, Mwanahamuntu, Kapambwe, Mkumba, Stringer, Sahasrabuddhe, and Parham (2010), the community can accomplish cancer prevention goals by providing services for interventions, community-based education, and support programmesthat will help ensure that appropriate goals are set. In a broader sense, programmesthat emphasize women's reproductive health needs and concerns should be prioritized since they will provide societal inputs for planning and implementing programmeinterventions and informational messages. The community- based participatory approach to programmeimplementation will be aided by the establishment of eventual programmatic sustainability and greater programmeeffect. According to Paul, Winkler, Bartolini, Penny, Huong, Nga, and Jeronimo(2013), a community mobilization plan that targets eligible (age appropriate) women, spouses, UNIV ERSITY O F I BADAN LI BRARY 26 and the broader community is needed. The plan should also include how messages about the lack of symptoms of precancerous lesions can raise awareness about cervical cancer screening; appropriate training for health promoters to deliver accurate information to their communities, including messages about the safety of screening and treatment; and coordination between outreach workers and service providers to ensure that women can travel to clinics at convenient times and be seen promptly. To be confident and skilled in their clinical abilities and programmes, health professionals require extensive training. Cervical cancer prevention may be possible with early detection and treatment. A well-coordinated cervical cancer screening programmeshould be implemented, focusing on at risk groups, for example elderly women (Nwozor and Oragudosi, 2013). To lower the prevalence of cervical cancer in Nigeria, these issues must be addressed. According to Nakisige, Schwartz and Ndira (2017), if cervical cancer preventive efforts are targeted correctly, delayed presentation of women with advanced cervical cancer can be avoided. It is critical to have the right radiotherapy equipment for the treatment of cervical cancer. According to Visanuyothin, Chompikul and Mongkolchati (2015), increasing cervical cancer screening adherence will help to reduce cervical cancer morbidity and death, particularly in metropolitan settings. Cervical cancer will be reduced in Nigeria through the deployment of mobile screening units, educational programmesabout the disease, encouragement from healthcare providers, and female peer leaders. When the population is educated about advanced cervical cancer screening proceduressuch pap smears, ocular inspection with acetic acid, and cervical tissue sampling, Konathala et al. (2017) believe that the spread of advanced cervical cancer will be dramatically reduced. Periodic educational interventions aimed at socially and economically disadvantaged women will increase short-term sexual risk behaviour reduction. According to Marlow, Chorley, Haddrell, Ferrer and Waller (2017), valuable information for screening providers regarding how to deal with low uptake can be classified based on the demographic disparities of non-participant types. When more exploration of attitudinal differences across different non-participant types is considered, useful guidance on the content of these targeted interventions may be provided. Regular health education of women, as well as clinicians' and other health UNIV ERSITY O F I BADAN LI BRARY 27 care professionals' recommendations of pap smear screening, will go a long way toward improving pap smear uptake, and ultimately reducing the incidence and burden of the disease, according to Okunowo, Daramola, Soibi-Harry, Ezenwankwo, Kuku, Okunade, and Anorlu, (2018). According to Ebu et al. (2018), CCS education should focus on HIV-positive women and those who are illiterate but are at high risk of getting cervical cancer. It is critical to promote education among both young and mature women, as it may play a key role in promoting healthy habits. 2.3 Gap in literature Previous studies on cervical cancer screening have looked into awareness (for instance, Tatar et al 2018, Markovic et al 2005, and Mukama et al 2017), women’s knowledge about CCS (for instance, Aweke et al, 2017, Sowemimo et al, Nwabichie 2018, and Geremew et al 2018),factors influencing CCS uptake (for instance, Rausl et al 2015, Ndejjo et al 2016, and Tiruneh et al 2017), socio-cultural factors influencing CCS uptake in both developed and developing countries (for instance, Ndikom et al 2012, Goodman 2013, Leinonen et al 2017, Nwobodo 2017, and Adegboyega et all 2019) and socio-economic factors influencing CCS uptake (Palacio-Mejia et al 2006, Gakidon et al 2008, Lee et al 2013, and Rohani-Rasaf et al 2018). However,previous studies on Cervical Cancer have largely focused on its biomedical contexts, with little attention paid to the social contexts affecting the knowledge and attitudes towards the uptake of Cervical Cancer Screening. Because there is a dearth of community-based studies on CCS uptake, especially in the study population, this study, therefore, investigated the awareness, knowledge, attitudes, perceptions of risks, and the socio- cultural factors influencing the uptake of the CCS among women in Oyo State, Nigeria. 2.4 Theoretical Framework The study is anchored on the Health Belief Model (HBM) as a theoretical guide for explaining the complexity of the economic, social, and cultural factors influencing the uptake of CCS in Oyo State, Nigeria. UNIV ERSITY O F I BADAN LI BRARY 28 2.4.1. The Health Belief Model Beliefs are the non-material socio-cultural fibre that shape behaviour in any society (Amzat and Razum, 2014). They are acquired alongside society’s general culture, during socialisation. Beliefs demonstrate crucial link between socialisation, and behaviour (Abraham and Sheeran2015). The HBM dates to the 1950s when US public health researchers developed psychological models for enhancing the effectiveness of health education programmes (Hochbaum, 1958; Rosenstock, 1966). The model became a psychological model that explains and predicts health behaviour by focusing on attitudes of individuals, using the dimensions of belief, and subjective perception from the viewpoint of social actors. Today, the HBM is the most commonly used theory in health education, and promotion as well as health service utilisation research (National Cancer Institute, NCI, 2003). Rosenstock (1974) recognised that Hochbaum in 1958 was the first to work on HBM research on uptake of tuberculosis X-ray screening. Hochbaum (1958) discovered that perceived vulnerability to tuberculosis, and the belief that people with the disease could be asymptomatic (making screening beneficial) distinguished between those who had, and had not attended for chest X-rays. In the same vein, a potential study by Kegeles (1963) identified perceived vulnerability to the worst imaginable dental problems, and awareness that visits to the dentist might prevent these problems, were variables that can predict the frequency of dental visits over a period of time. Kegeles (1963) studied the relationship of belief, and attitudinal variables to preventive visits. Haefner, and Kirscht (1970) further demonstrated that an HBM-based health education interv