Date of Award


Document Type


Degree Name

Master of Medicine (MMed)

First Supervisor/Advisor

Prof. Marleen Temmerman

Second Supervisor/Advisor

James Orwa


Obstetrics and Gynaecology (East Africa)


Background: The cancer burden has been rising globally. The reported incidence of cervical cancer is 13.1 / 100,000 globally and 40 / 100,000 in Kenya. Up to 88% of all cervical cancer deaths have been reported in lower to middle-income countries. In comparison, developed countries had up to two to four times lower rates of cervical cancer incidence and mortality. The burden of cancers attributable to carcinogenic infections has potentially modifiable risk factors, for which prevention tools already exist. There is a gap in the implementation of evidence-based interventions including primary prevention with the HPV vaccine and secondary prevention with screening and treatment of early precancerous lesions. Both structural and personal impediments to screening programs commonly encountered in sub-Saharan Africa include lack of availability, accessibility, affordability of health services, limited resources, lack of awareness, high HIV burden, poor health-seeking behavior, and psychological factors. The Kenyan government is rolling out cervical cancer screening programs, but the coverage is still low, mainly due to lack of awareness, knowledge, lack of services, and cost of screening, fear, ignorance, and stigma. Therefore, we decided to study the level of screening and determinants of screening, in a well-educated population with good medical coverage, health insurance, and availability of services, to understand the factors that play a role even in this population. In addition, we decided to explore the role of men in the prevention of cervical cancer. Traditionally men have not been involved in reproductive health, as it has always been considered as a woman’s domain. Policy development in family planning has engaged men in taking a proactive role and this has seen acceptability and increased uptake of family planning services, which could be modeled in other preventive and promotion programs of screening for cervical cancer.

Methods: We performed a descriptive cross-sectional study recruiting from a population of 2246 healthcare staff offering direct or indirect health services in the Aga Khan University Hospital, Nairobi, Kenya. The study population was stratified into clinical, administrative, and support staff. The nonprobability sampling method was done proportionately to the size of the population to ensure equal representation. Using the prevalence calculation, 362 participants were invited and directly approached after adjusting from the finite population. Data were obtained using a validated semi-structured Cervical cancer Awareness Measure questionnaire (CAM tool). Which collected data including socio-demographics, screening practices and attitudes, advocacy, and knowledge on vaccination. The present study used the Chi-square test for data analysis and further explored the data for an independent variable using multivariate logistic regression. The perceived psychological barriers to health-seeking behavior seen in the study were discussed using the Health Belief Model for the identification of actions to achieve efficacy in the uptake of cervical cancer screening.

Results: Out of the 362 invited staff, 352 agreed to participate in the study (97.2 % response rate), with 295 (83.8%) females and 57 (16.2%) males. Out of the 295 females, 183 (62%) (95% CI: 56.2% to 67.6%) had ever been screened for cervical cancer while 112 (38%) were never screened. Factors associated with cervical cancer screening included age above 30 years, parity, marital status, insurance cover, exposure or caring for a cervical cancer patient. On prevention of cervical cancer, 271 (77%) both males and females participants knew the correct age of vaccination, and 24 (8.1%) of the female participants had been vaccinated for cervical cancer. Only 36 (10.2%) of both females and males participants believed in the protective effects of the vaccine, 149(50.5%) of the female participants and 25(43%) of male participants did not believe that vaccination is protective against cervical cancer. On the uptake of routine screening among the 183 females who had ever been screened, 30 (16.4%) had three yearly screening results, with 153(83.6%) were either screened or awaiting due screening interval or not following the recommended interval for screening after the initial screening. Of the 112 females who had not screened for cervical cancer, 59 (52.7%) cited the test as invasive. Out of the 41 (13.9%) female participants who declined future screening opportunities, 68.3% cited psychological factors including fear of the procedure. Of the male participants 42 (63.7%) knew the status of screening of either their partner or close family member with only 9 (15.8%) correctly identified the recommended age of screening. Forty-four (77.2%) males were aware of the availability of cervical cancer vaccine though only 6(10.1%) thought that vaccination against cervical cancer was protective. Insurance cover was high in this population with 294 (83.5%), with a majority of 303 (86.1%) being aware of the cervical screening program availability. Health education was the primary source of current knowledge for 262 (74.4%), while only 103 (29.3%) relied on media as their source of cervical cancer knowledge. Women who had high knowledge of cervical cancer were twice as likely to be screened for cervical cancer as those with low knowledge of cervical cancer (AOR: 2.085; 95% CI: 1.212-3.631).

Conclusions: The study illustrates a 62% screening rate in healthcare workers in a private tertiary hospital with minimal to no structural barriers to screening. Personal psychological barriers, including fear of the screening procedure, were the principal reasons for not screening or going for routine screening. In Aga Khan vii University Hospital, there is still an opportunity to increase the acceptability of the test by addressing the psychological fear of the procedure. This can be done by filling of surveys in each vist and counselling of the patients before the procedure. Innovative screening services can be assessed and offered as an alternative to the regular pap smear, so as to increase acceptability of conducting the screening procedure. Likewise, the structuring of education programs can be included in the policy to focus on cervical cancer, screening practices, and importance of vaccination. In addition, cues for action like media campaigns, training programs, and yearly message reminders for screening will aid in increasing cervical cancer screening rates. The findings of this study will be important to share with the governmental and non-governmental stakeholders focusing on cervical cancer screening barriers. The identified personal barriers together with the existing structural barriers need to be addressed in vulnerable populations to improve future cervical cancer screening rates in Kenya. Likewise, implementation of the existing study findings and evidence-based interventions can help achieve the goal of elimination of this preventable cancer.