Effect of a Health Communication Strategy on Uptake of Cervical Cancer Screening in Isiolo County, Kenya

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Introduction
The global burden of cervical cancer is high, with 604,000 new cases of cervical cancer in 2018 and 342,000 deaths as a result of the disease (Sung et al., 2021). In developed countries, such as the United Kingdom (UK) and the United States (US), the incidence of cervical cancer has reduced, owing to the implementation of population-wide screening programmes (Jedy-Agba et al., 2020). The incidence rate in Eastern Africa is 40.1 per 100,000 women (Ferlay et al., 2019) compared to the United States of America which has an incidence rate of 7.8 per 100,000 women (Swanson et al., 2018). In Kenya, there are 5250 new cases of cervical cancer recorded each year, and there are 3286 related deaths (MOH, 2018).
A major barrier to cervical cancer screening in rural Kenya is inadequate knowledge (Rosser et al., 2015). The community strategy is an effective method of reaching out to women of reproductive age at the basic health care level where 80% of citizens live (Kimani et al., 2012). Health communication strategies include use of electronic (e.g. internet, radio, social media) and non-electronic (e.g. print media, face-to-face communication) media (RHIhub, 2017). Community health volunteers form part of the community strategy workforce where they play key roles including door-to-door visits to teach health-related preventive methods and collecting data from each household (Kuule et al., 2017;Kawakatsu et al., 2012). The CHVs, in their regular and routine home visits, disseminated information on cervical cancer screening to women at the community using a lesson plan modified from CHVs training module 13. The study was to supplement current initiatives to increase cervical cancer screening uptake in Isiolo County and beyond, supporting the WHO's goal of eradicating cervical cancer by 2030.

Study Population
The study population was women at the community in Isiolo County, Kenya. The County consists of Isiolo, Merti and Garbatulla Sub Counties. The County population is approximated at 268,002 with high illiteracy levels are high, with 20% of the population not having gone to school (Census, 2019). Over 68% of persons in Isiolo County are nomads who live in rural areas where most dwell in temporary houses known as 'Manyattas'. Only 14.5% of the population are formally employed. The study area was divided into 40 functional community health units, with each unit linked to the nearest health facility.

Study Design and Sampling Technique
This study adopted a community-based cluster randomized trial. Cluster randomized trials focus on external validity and effectiveness of public health interventions (Hunter et al., 2013).
Multi-stage sampling method was used to derive the required sample size. Isiolo County was purposively selected for this study. A sampling frame of 40 (forty) community units in Isiolo County was prepared. The community units were then operationalized into clusters. Six clusters were randomly selected from all the clusters using simple random sampling. The six clusters were then randomly assigned into either intervention or control arm of the study. A sample size was computed and apportioned to each arm of study. Every cluster was proportionately allocated the number of households to be included in the study. Systematic random sampling was then used to select the study participants at household level for intervention and control arms.

Sample Size Determination
Hospital based data showed that 5% of women in Isiolo County are screened for cervical cancer (DHIS, 2018) For a dichotomous outcome of interest, the formula to calculate sample size was adopted from Chan, (2008) as follows; Figure 1. Data collection process  Table 1 shows the comparison of respondents' socio-demographic and socio-economic characteristics in the study's control and intervention arms. The two study arms did not significantly differ from one another However, post-intervention those screened for cervical cancer increased to 142(32%) of the total respondents.   Table 2 indicates that at endline, awareness of gynecological diseases was more in the intervention arm 123(55.4%).

Existing Strategies Used to Enhance Uptake of Cervical Cancer Screening in Isiolo County
Those who named cervical cancer as a gynecological disease in the intervention arm were 40(18.0%) while in the control arm were only 6(2.7%).  Table 3 indicates that there was a significant association between cervical cancer screening and awareness of gynecological diseases (p-value<0.01). At endline awareness of cervical cancer increased from 28.2% to 40.5%(p-value<0.01). All other knowledge variables were significantly associate with uptake of cervical screening at endline.  Table 4 indicates that the respondents who correctly named the signs and symptoms of cervical cancer were 3.849 times more likely to be screened than those who did not state any sign and symptom (OR 3.849, p = 0.001; CI.1.802-8.223).    Table 5 indicates that the respondents who received health communication were 2.265 times more likely to be screened than those who did not receive health communication (OR 3.867, CI.1.802-8.223, P < 0.001).

Discussion
In Isiolo County, the uptake of cancer of cervix screening among women was low in the outset.
According to research findings (Ngugi et al., 2012;Were et al., 2012;Ng'ang'a et al., 2018), cervical cancer screening levels in Kenya are low, below the anticipated national target (Kenya National Screening Guidelines, 2018). The uptake is similarly low in other developing countries (Lyimo & Beran, 2012;Tiruneh et al., 2017). However, in developed countries, the level of uptake for cervical cancer screening is high due to effective screening programmes (Vaccarella et al., 2017;Dessalegn Mekonnen, 2020).
Some of the respondents indicated that they had never been screened for cervical cancer. Their reasons for not screening were; being busy, lack of knowledge about screening and others did not have any reason at all. (Kisiangani et al., 2019) identified reasons for not screening as lack of knowledge and fear of screening. Another study found out that women were not screened because they had never heard about the disease and financial problems (Aweke et al., 2017).
The existing health communication strategies in Isiolo County were limited in addressing cervical cancer. At baseline, it was noted that cervical cancer screening information was minimally disseminated by the Community Health Volunteers, as they concentrated on other health-related issues such as antenatal care, breastfeeding, hygiene and covid-19 pandemic (Wanja, 2018;Sohrabi et al., 2020;Kisiangani et al., 2019). However, at endline, the respondents indicated that the Community Health Volunteers communicated about cervical cancer screening in the intervention arm of study. Studies have showed that face-to-face education intervention to be effective in cervical cancer screening and subsequently increasing uptake strategy was also used by healthcare workers at the facility level to disseminate information on cervical cancer screening. However, the communication on cervical cancer screening was minimal as most of the respondents indicated that the healthcare workers communicated about other health conditions, particularly COVID-19. This was as a result of the country and the world dealing with the COVID-19 pandemic at the time of study (Sohrabi et al., 2020;Kisiangani et al., 2019). The behavior of women about cervical cancer screening was found to be improved by face-to-face intervention (Naz et al., 2018). By lowering barriers to cervical cancer screening, a face-to-face educational intervention can help to boost uptake (Coronado et al., 2015;Naz et al., 2018).
Other communication strategies used to enhance of cervical cancer screening at the county included: social media; friends, family and religious gatherings. It was noted that 30.2% of the study respondents did not mention any communication strategy used to enhance cervical screening at baseline. One of the main causes of the low uptake of screening for cervical cancer has been identified as a lack of information (Aswathy et al., 2012) whereas adequate information improves rates of screening (Naz et al., 2018).
Most improvement of knowledge variables was realized in the intervention arm of study. The study's intervention arm had more respondents than the control arm who could define the term "cervical cancer." (p = 0.001). At endline, the respondents who correctly named cervical cancer signs and symptoms were three times more likely to be screened as compared to those who did not correctly name the signs and symptoms. In comparison to the control arm, the intervention arm respondents had more knowledge at endline. Respondents with increased knowledge were 3.849 times more likely to be screened than those with inadequate knowledge. According to a research conducted in the counties of Tharaka-Nithi and Isiolo to determine knowledge of cervical cancer screening, respondents had insufficient knowledge, which hindered the rate of uptake (Ngari et al., 2021).
A study in Ethiopia, on knowledge of cervical cancer, concluded that inadequate knowledge was a potent barrier to screening. Community-based interventions to disseminate knowledge on cervical cancer screening were recommended with a resultant effect of increased uptake (Chaka et al., 2018). Increased uptake was reported in a study that determined the association between level of knowledge and cervical cancer screening (Agboola & Bello, 2021). Another study in Ivory Coast showed that over half of the respondents in a study on cervical cancer screening were aware of cervical cancer (Boni et al., 2021). Adequate knowledge of cervical cancer screening was reported in a study among Brazilian women (Stormo et al., 2014). Other studies that have associated cervical cancer screening with increased uptake include (Agboola & Bello, 2021, Boni et al., 2021and Musa et al., 2017. Despite inadequate knowledge, there was an increase in the uptake of screening for cervical cancer in a Cameroonian study (Ekane et al., 2015).
Pre-intervention uptake of screening for cancer of cervix was 18.2%; post-intervention uptake in the intervention arm was 45.9%; post-intervention uptake in the control arm was 18.0%. Cervical cancer screening uptake was significantly associated with intervention, with respondents who received health communication being 3.867 times more likely to be screened than respondents who did not. Studies where Community Health Volunteers provided information on cervical cancer screening to the community revealed increased adoption of cervical screening. (Goodman & Nour, 2014;Lott et al., 2020;Chigbu et al., 2017). Another study carried out in Nigeria showed that health education increased the uptake of cervical cancer screening among respondents in the intervention arm compared to the control arm of the study (Abiodun et al., 2014). The percentage of women screened between the intervention and control arms of the study pre-and post-intervention did not significantly differ in another health education intervention study, though (Gana et al., 2017).

Conclusion
Cervical cancer screening rates were low prior to intervention. Some of the reasons for not screening were; inadequate knowledge, fear of being screened and feeling healthy thus requiring no screening. Increased knowledge of cervical screening post-intervention was significantly associated with increased uptake.
The factors which were found to influence cervical cancer screening post-intervention included knowledge and attitude. Post-intervention there was a positive change of attitude in the intervention arm of the study which was significantly associated with increased uptake. Increased knowledge was shown in the study's intervention arm and was significantly associated with higher uptake of cervical cancer screening.