This is one of the first studies describing knowledge and beliefs about cervical cancer and screening among a population of women in Ghana. Overall we found good awareness of the issues related to screening, although there were specific gaps in knowledge about risk factors and screening intervals. For instance, we found that although the relationship between sex and cervical cancer was known, less was known about other risk factors (their partner's prior sexual experiences, smoking, diet, and family history) and very little was known about the link between HPV and cervical cancer. This result is not unexpected, given that literate young women in a college environment might have been exposed to public health education messages on sexually transmitted diseases, especially HIV/AIDS. However, according to the American Cancer Society HPV is the most important risk factor for cervical cancer (21
). A notable finding is that only 7.9% of students knew about HPV. This low level of knowledge has implications for future strategies to prevent cervical cancer with the HPV vaccine. Our study findings mirror those of Adanu who also found that Ghanaian health science students, workers, university professors and staff persons in the health professions had adequate knowledge about cervical cancer, compared to those without a medical background. They also observed a good understanding of the role of sex and multiple sexual partners in the etiology (1
). However, a cause for concern is that even in these highly educated populations, there is a lack of knowledge about the role of HPV.
Ghana does not have an active national screening program with guidelines that are widely disseminated to the public. It is not surprising that very few students could identify the most commonly recommended screening start age and interval for young adults in other countries or alternative screening recommendations in other African countries (21
). The Ghana Government official document on reproductive health admits that “although the Pap smear was the encouraged primary prevention strategy for cervical cancer, the cost involved in setting up a national screening programme based on Pap smear was the one factor that limited the setting up of such a programme” (16
). We could conclude from these results that, in general, the absence of an actively promoted national cervical screening program has resulted in a lack of basic knowledge about important risk factors for cervical cancer and a lack of information on screening age and intervals. College students are among the most informed group of women in Ghana. Their lack of knowledge on cervical cancer and the need for periodic screening is indicative of a greater lack of awareness among the larger population of less educated women, as reported in other African populations (17
The Health Belief Model postulates that people will engage in health seeking behavior if they perceive benefits to themselves accruing from that behavior. The fact that students of the University of Ghana perceive that cervical screening is beneficial is encouraging and suggests that a program of public education within the context of a national screening program is likely to result in increased screening uptake and repeat screening among women.
Women are also more likely to engage in health-seeking behavior if they perceive the cost and barriers to such a behavior to be reasonable. This population had good awareness of barriers to screening, furthermore, we found three of these barrier variables to be correlated with screening in this population. The first was the belief that the purpose of a pap smear is to diagnose cancer, this could be potentially easily addressed by the provision of information. However, some of the other important barriers (whether their partner would want them to have a pap, whether a pap would affect their virginity and fear that the public may think that a young woman who goes for cervical screening is having sex) suggest that there are cultural and traditional beliefs about societal roles that are influencing these responses. This finding has implications for public health interventions and suggests that broad based public health initiatives will be needed to overcome these barriers. Other important barriers that were mentioned, such as lack of information about screening sites, are more logistical in nature and are relatively easily addressed with simple information provision. Cost barriers were mentioned by a quarter of respondents and may be resolved when the Ghana government makes cervical screening part of subsidized routine healthcare for women. This population also demonstrated some fatalistic beliefs about cancer (If I am destined to get cancer, I will get it no matter what
) that have also been reported in elderly minority populations in the US. These may be additional cultural barriers to screening, rooted in faith, that will need to be explored further, and addressed, particularly in older and less educated populations, in whom they may be more prevalent. (24
The high level of perceived susceptibility to cervical cancer probably had much to do with the word cancer. The students also understood quite well that cervical cancer is a serious disease that is likely to make a patient's life very difficult even though most believed there is a cure for it. The public health implication of this perception of a cure may be the tendency among students to take screening recommendations less seriously. This possibility must be addressed as part of any screening program by emphasizing that curability is related to stage of disease.
In general, women reported very few cues in the media or from primary care physicians and other health care workers about the importance of cervical screening. A higher percentage of students who were prompted by a healthcare worker obtained screening. Even if a national screening program is introduced as part of routine care for women, the absence of appropriate cues from the media, healthcare workers and peers is likely to hamper screening uptake. Media messages, healthcare worker reminder and outreach have been used to raise screening rates in communities in other parts of the world (25
). This suggests that primary healthcare workers such as community health nurses should be an important part of any new program aimed at increasing cervical cancer screening rates.
Our population included young college women, and this has implications for the generalizability of the findings to less educated or older women. The cross sectional nature of the survey means causal inferences cannot be made from the results reported. Furthermore, the survey was self administered and is therefore open to the usual reporting biases inherent in such surveys. However, we believe that this was minimized because the survey was anonymous. Strengths of the study include the fact that we were able to access a population that has not been widely studied, and that this is one of the first studies describing knowledge and beliefs about cervical cancer in this population and reveals potential targets for interventions to improve cervical cancer screening rates.
In conclusion, this study showed that a literate population of college women in Ghana lack complete information on cervical cancer and its risk factors. Perceived barriers to screening have the most significant influence on screening behavior and this is in line with the literature in other populations (26
). From a public policy point of view, it may be important to further explore the extent to which perceived barriers to screening will affect screening uptake when a national screening program is implemented. In order to influence perceptions, strategies will have to address these barriers by targeting the women themselves, but also society at large and ensure that eligible women receive the right screening cues from both the media and healthcare workers.