Background

Globally, cervical cancer is the fourth most common type of cancer with 569 847 new cases and 311 365 deaths annually among women. The global age-standardized incidence rate per 100, 000 is 13.1 [1]. The Sub-Saharan African cervical cancer deaths constitutes 21.6% of the global cancer deaths; ranking the continent’s burden in the second position after India (25.4%) [2]. Secondly, Sub-Saharan Africa has the region (Eastern Africa) with the biggest burden (52613 new cases) of the disease globally [2]. Despite the significant burden posed by cervical cancer, the international policy framing demonstrates the members’ commitment to averting the disease [3, 4]. The international cervical cancer framing emphasizes the importance of cervical cancer screening for women age 25–49 years [4]. The significance of ensuring equity in access to sexual and reproductive health-care services was also fronted as a fundamental human right by the Sustainable Development Goals (SDGs), especially goals; 3 and 5 [3]. The international policy framing also recognized the importance of the intimate-partner in improving the maternal reproductive health outcome [5, 6]. The significance of intimate-partner factors in improving reproductive health first gained an international platform during the 1994 International Conference on Population and Development in Cairo [5]. Later, the 1995 women’s Conference in Beijing agitated for shared responsibility between men and women on reproductive health matters to improve women’s health [6]. The World Health Organization also recognized the importance of integrating men in the prevention of cervical cancer in Low and middle-income-economies [7].

Cervical cancer is the principal cause of cancer related deaths among women in most Low and Middle Income Countries (LMICs), Uganda inclusive [2]. Uganda is among the seven countries with the highest cervical cancer incidence rates [2]. Uganda’s age-standardized incidence (54.8) and mortality (25) rate per 100, 000 is over four folds the global estimate of 13.1 and 6.8 respectively [1]. Close to half (40%) of all cancer cases recorded by Kampala Cancer Registry (KCR) are as a result of cervical malignancy [8]. The 2018 estimates indicated that about, 6413 new cases and 2400 deaths due to cervical cancer were registered in Uganda [9]. Additionally, about 80% of the female cancer patients at the Uganda Cancer Institute are diagnosed with cervical cancer. As Uganda aspires to attain the middle income status, the burden of cervical cancer is also likely to escalate with adoption of unhealthy lifestyles [10, 11]; Uganda’s cervical cancer burden is projected to account for about, 6400 new cases and 4300 deaths annually by 2025 [12].

Widespread cytology-based screening has proven to be efficacious in reducing cervical cancer incidence and mortality in developed countries [13]. However, LMICs have not seen equivalent interventions, hence perpetuating inequality in the burden of cervical cancer between developed countries and LMICs [1]. The disparity in the burden of cervical cancer between developed countries and LMICs can be significantly narrowed if LMICs implement cervical cancer screening programs [13, 14]. Ensuring effectiveness of cervical cancer screening programs in LMCs will call for leveraging access and uptake [15, 16]. The Ministry of Health strategic plan for cervical cancer prevention and control 2010–2014 targeted to screen and treat 80% of eligible women aged 25–49 years by 2015 [17]. However, the uptake of services is still low (7%); according to study from Central Uganda [18]. The low uptake of cervical cancer screening is attributed to financial constraints, and lack of awareness related to cervical cancer screening [19]. Additionally, studies have indicated that inadequate male participation may be an underrated impediment to cervical cancer screening [20].

Several studies have underscored the role of intimate-partner factors in influencing reproductive health outcomes of women including; maternal and child health [21, 22], reproductive health [23, 24], labor preparation [25, 26], and contraceptive use [27]. The abovementioned studies point to scarcity of evidence regarding intimate-partner factors and cervical cancer screening. Research has associated cervical cancer screening with some intimate-partner factors; women who had experienced intimate partner violence were less likely to have ever screened compared to their counterparts in Kenya [37]. Some studies have also recognized the intimate-partner factors associated with spouses’ cervical cancer screening including; participating in decision-making, granting permission, providing transport, and financial support to attend health services cited by studies in; Ghana [28], Swaziland [29], Kenya [30], and among Sub-Saharan immigrant men in the United States of America (USA) [31]. Additionally, research has also associated cervical cancer screening with several individual factors. These include; women’s age [32–34] and women’s social economic status [32, 35]. Majority of the studies on cervical cancer screening uptake in Uganda focused solely on women without controlling for intimate-partner factors [36], vanishing the ground for testing the social support theory vis-à-vis cervical cancer screening.

Evidence has demonstrated that men influence the reproductive health outcomes of women; men impact women’s reproductive health through their role as intimate-partners, fathers, and healthcare workers [26, 37–39]. This is because, in some developing countries with patriarchal structures, the effect of intimate-partner factors are even more pronounced. The husbands or other family members control women’s health-related decisions, access to health care facilities and the use of family resources [39, 40]. The aforementioned literature on cervical cancer screening is inconclusive about the women and intimate-partners’ factors of cervical cancer screening in Uganda. The main objective of the study was to establish women and intimate-partners’ factors of cervical cancer screening in Central Uganda. The findings of the current study will inform effective interventions related to gender balance in men’s and women’s cervical cancer screening rights and responsibilities.

Methods

We conducted a population-based cross sectional-survey in two of 27 districts in Central Uganda during June and July 2019. The two districts include Wakiso; a peri-urban area near Kampala city and Nakasongola district; a rural district. Cervical cancer prevention interventions have been implemented in these two districts [17]. Approval to conduct the study was obtained from Makerere University School of Social Sciences Research and Ethics Committee (MAHSSREC) and the Uganda National Council of Science and Technology (UNCST); UNCST registration number SS4848. Entry into the communities was cleared by the district as well as local authorities. Voluntary written informed consent was obtained from all participants, and they were assured of confidentiality before initiating interviews. Participants were also informed of their freedom to decline participation if they chose. These women were also abreast of their right to join the study and withdraw at any point without fear of retribution from the study team. The study participants were granted modest time (5–10 minutes) to ask questions about the study subject shortly after the interviews.

Results

Distribution of study participants by demographic, socio-economic, and intimate-partner factors

Results in Table 1 shows that, majority of the respondents were from an urban setting (Wakiso district) (70%), in the middle wealth class (63.4%), and had ≤3 children (69%). Most women used contraceptives (60.5%) and their age at first marriage was 19–34 years (64.5%). Half of the women had attained secondary education (50%), approximately 3 in 10 (30.6%) were Protestants, 41.8% were engaged in business, 37% were Baganda and 45.9% were aged 30–39. Four in ten (40.4%) of the intimate-partners were engaged in business. The majority of the intimate-partners were also aged 35–49 (63%), had attained secondary education (54.7%), had one wife (74.7%), were the decision makers regarding spouses’ health (79.3%), and had never offered screening emotional support (97.7).

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Table 1. Distribution of study participants by demographics, socio-economic factors, intimate-partner factors and cervical cancer screening status (N = 656).

https://doi.org/10.1371/journal.pone.0274602.t001

Table 1 also shows the results of the cross tabulation (chi-squared tests) between demographic factors, socio-economic factors, intimate-partner factors and cervical cancer screening. Cervical cancer screening was significantly associated with women’s age (p = 0.014), education attainment (p = 0.009), occupation (p = 0.018), wealth index (p = 0.010) and parity (0.075). Intimate-Partner’s factors that were significantly associated with spouse’s cervical cancer screening included age (p = 0.009), education attainment (p = 0.034), and obtaining screening related emotional support (p<0.001).

Cervical cancer screening was higher among women aged 40–49 (25.7%), who had attained post-secondary education (29.6%), the rich (30.8%) and women with 4 or more children (23.3%). Cervical cancer screening was also higher among women whose spouses were age 35–49 years (23.8%), and had attained post-secondary education (34.9%). Cervical cancer screening was also higher among women whose spouses had extended screening related emotional support (80%) and screening related financial support (94.3%). Women’s religion, study site, ethnicity, age at first marriage and use of contraception were not significantly associated with cervical cancer screening. Intimate-partner’s decision-making authority, number of wives and occupation were also not significantly associated with cervical cancer screening.

Associations between socio-demographic, economic, and male partner factors with cervical cancer screening

In Table 2, we estimated complementary log-log regression models to examine the relationship between cervical cancer screening and women’s background characteristics, controlling for male partner factors. The first model consisted of women’s background characteristics namely; age, education attainment, wealth index, parity and occupation. In the final model, we added male partner factors. None of women’s characteristics consistently retained its significance after controlling for male partners characteristics. Women’s education lost significance after controlling for male partners characteristics. In the first model, women who had attained post-secondary education had increased odds of having ever screened compared with women who had attained primary education (OR = 2.00; CI 1.07–3.76).

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Table 2. Associations between socio-demographic, economic and male partner factors with cervical cancer screening.

https://doi.org/10.1371/journal.pone.0274602.t002

In the final model, women’s education remained significant after controlling for male partner characteristics. Women who had attained secondary education had increased odds of having screened compared with women who had attained primary education (OR = 2.19; CI 1.18–4.06). Women whose partners had extended screening related emotional support had increased odds of having screened compared with their counterparts who did not receive spouse emotional support (OR = 30.06; CI 13.44–67.20). Women whose partners had extended screening related financial support had increased odds of having screened compared with their counterparts (OR = 53.94; CI 30.66–94.87). Women’s age, wealth index, occupation and parity were not significantly associated with cervical cancer screening in any of the two models. The partners’ age and education attainment were also not significantly associated with cervical cancer screening.

Discussion

The present study sought to establish the intimate-partner factors associated with cervical cancer screening among married women in Central Uganda. Women’s education attainment, intimate-partners’ financial and emotional support were significantly associated with cervical cancer screening among married women in Central Uganda. Our findings indicate that only 20% of the married women in Central Uganda had ever screened for cervical cancer. This finding from the current study is higher than findings from Eastern Uganda (4.8%) [36], and Zimbabwe (9%) [35]. Most of these studies were health facility based, focus on one type of residence, and had small sample sizes. However, our findings are close to findings published from Tanzania (22.6%) (20), Kenya (19.4%) [32] and Nepal (18.3%) [33]. The low cervical cancer screening rate among married women in Central Uganda is of great concern and attests to the need to scale-up cervical cancer screening services to all health facilities in Central Uganda and other regions of the country.

When woman and intimate-partner’s factors were examined simultaneously in relation to cervical cancer screening, only women’s education attainment and intimate-partners’ emotional and financial support were significantly associated with screening status. It was found that the likelihood of screening increased among women with secondary, and post-secondary compared with their counterparts with none/ primary education. The possible explanation is that, educated women are more likely to be empowered and informed about their health [49, 54–56]. Our finding is consistent with findings from other studies [33, 57]. However, our study results are not supported by findings from El Salvador study [58]. The difference in the findings may be explained by the context in which the two studies were done; the El-Salvador study was done in an area with cervical cancer screening program, yet the current study was done in an area without organized cervical cancer screening program. Our result point to the need for awareness campaigns in communities targeting illiterate women or those with primary education to motivate them to embrace cervical cancer screening.

In this study, two different dimensions of spousal/ social support were significantly associated with cervical cancer screening. First, the likelihood of cervical cancer screening increased among women who had benefited from intimate-partners’ social support in the form of information compared with their counterparts. Our research concurs with findings from low-resource countries (synthesis of research projects in Bolivia, Peru, Kenya, South Africa, and Mexico) [59]. Our finding is also supported by results from studies done in Nigeria, which indicated that women required spousal-information-support before completing cervical cancer screening [60, 61]. Our research underscores the spousal/ social support function of social networks, especially marital relationships [62]. Therefore, our study point to the importance of making social networks an integral component in the interventions that aim at increasing cervical cancer screening. Additionally, the likelihood of cervical cancer screening was higher among women who reported receiving spousal financial support compared with their counterparts. Financial support is classified by the social support theory as instrumental support and is believed to have a positive influence on health [62]. Our result is supported by previous studies where women cited financial constraints as barriers to cervical cancer screening [19, 29, 31, 63, 64]. Our study findings suggest that awareness and health education programs on women’s health needs should consider and involve men; to reinforce intimate-partners’ roles in cervical cancer screening. Our study examined intimate-partner’s cervical cancer screening support, yet social support research through the relationship perspective has suggested that health outcomes of social support are not independent of relationship processes; they simultaneously occur with support, such as intimacy, companion, and low social conflict, calling for further research in this area [62]. Contrary to our hypothesis, intimate-partners’ education attainment was not significantly associated to their wives’ cervical cancer screening, though the odds ratios indicated that the likelihood of screening was higher among women whose intimate-partners had secondary education. This may point to the minimum level of intimate-partner’s formal education necessary to positively influence the health outcomes of their spouses. Our study results are in consonance with previous studies [29] which did not find significant relationship of intimate-partners’ age with their spouses’ screening status. However, our study findings are not supported by findings from Tanzania [24]; this study found a positive, significant relationship between cervical cancer screening and intimate-partners’ age.

Surprisingly, wealth status was not significantly associated with cervical cancer screening, though the odds ratios indicated a positive relationship between wealth index and cervical cancer screening. This is because higher social economic status is associated with access to health services. A positive relationship between wealth status and cervical cancer screening was found in Eastern Jamaica [34], Zimbabwe [35], and Kenya [32], though statistically significant. It was hypothesized that higher parity was significantly associated with cervical cancer screening. Surprisingly, the study results show that parity was not significantly associated with cervical cancer screening though, the odds ratios indicated a higher likelihood of cervical cancer screening among women of higher parity. Studies from elsewhere indicated a positive, significant relationship between parity and cervical cancer screening [33, 34]. Higher parity coincides with older women who are most likely to see health workers after experiencing signs and symptoms [33]. However, our findings are inconsistent with findings from Jamaica [34] and Nepal [33] which found a positive significant relationship between parity and cervical cancer screening. Type of residence was not significantly associated with cervical cancer screening though, the odds of cervical cancer screening were higher among urban dwelling women. Our findings are not supported by findings from Tanzania [21], where maternity care was significantly associated with type of residence. Age was not significantly associated with cervical cancer screening, though the odds for cervical cancer screening were higher among older women compared to their younger counterparts. This finding indicate that screening uptake is independent of age; other factors may be responsible for screening among both the old and young women [65]. However, this finding is contrary to studies from elsewhere [32, 34] as they indicate a significant influence of age on cervical cancer screening.

Conclusion

This study found low uptake of cervical cancer screening (20%). In Central Uganda, cervical cancer screening among married women was significantly associated with women and intimate-partner factors; women’s education attainment, intimate-partner’s emotional and financial support were significantly associated with cervical cancer screening. The intimate-partner’s factors associated with cervical cancer screening point to traditional marital roles of male partner dominance. Efforts to encourage men’s participation through community education is recommended. This should be supplemented with empowering women through education to increase uptake of screening services.

Supporting information