Several significant findings are revealed in this study. First, less than one quarter (22.6%) of women in the rural area of Tanzania had ever screened for cervical cancer. This proportion is similar to uptake rates reported in various regions within Tanzania [11
] and in Nigeria [19
]. Thus, it seems that women from different districts with Eastern Africa report similar rates of cancer screening use.
Second, several factors examined individually in relation to the likelihood of screening indicate that uptake is likely when women report that their husband approves of the screening; have a college education; have a high level of knowledge about cervical cancer and how to prevent it; report little embarrassment and pain associated with the cancer screening procedure; have no preference for the sex of health provider who will screen them for cervical cancer; are aware of a nearby facility; and live within a 5 km proximity. Although marital status was not related to screening status, when husbands approved of screening, women were likely to obtain the screening. Thus, their support is an important factor to consider. In societies where men have a dominant role over their wife's health seeking decisions, men's approval becomes an integral part of the women's health behaviors. It is an important intermediate step along the path to the cervical cancer screening practices. Disapproval of the service reflects a lack of personal interest or hostility to the subject. Our findings revealed that husbands' approval of cervical cancer is strongly associated with participants' cervical cancer screening status. This is confirmed by Singh et al.'s [14
] study, which showed that a negative attitude of men towards screening or treatment of cervical cancer is considered a key factor contributing to poor uptake of services. Another study done in India revealed similar results [23
]. In addition, women with college education had screened for cervical cancer more often compared to their counterparts. Several other studies have found the same result [11
]. However, a study conducted at the University of Ghana indicated that few college women screened [1
]. This discrepancy can be explained by the importance of knowledge of cervical cancer. Despite their level of education, the Ghana students lacked knowledge about cervical cancer and its prevention specifically, and this factor was significant in our study.
In addition to knowledge, attitudes are related to screening status. Those women who did not have a preference for the sex of health provider were more likely to have screened for cervical cancer compared to those who preferred a female health provider. Thus, it is important that women who prefer a female health worker be assured that they can indeed access one [18
]. Women who thought the test was embarrassing were also less likely to obtain screening, which has been supported in other research [15
]. Perhaps it is less embarrassing to show private body parts to a female rather than a male health worker. Also, the likelihood of screening is also higher for women who did not believe that it was painful, which is consistent with other studies [17
Perhaps they are more tolerant of the physical discomfort of the procedure. Finally, location was related to screening status. Women who were aware of a facility which provides cervical cancer screening service were likely to obtain screening. Similar findings were obtained in a qualitative study conducted in Sudan which revealed poor awareness of services as a significant barrier [15
The third major finding is when these factors are examined simultaneously in relation to screening, only women's knowledge about cervical cancer and its prevention, and accessibility to a screening facility are significantly associated with screening status. In other words, when women are knowledgeable and live close to a facility, they are likely to seek screening, regardless of demographic and attitudinal factors. Understanding the importance of screening provides women with a valid reason for seeking this service. Having full information about the cervical cancer and its prevention gives women the ability to make an informed decision. It is also likely that women become knowledgeable about cervical cancer screening as a result of seeking the service. Also, the distance women have to travel to obtain this service is critical due to cost and limited access to transportation. The results are consistent with the Health Belief model, whereby those with perceived benefits are more likely to take preventive actions, than those with no perceived benefits or low perceived benefits [24
This study has some limitations. First, it was conducted in the community of Moshi rural district, which may not be generalizable to other areas. Second, the method of interviewing may have influenced the results. That is, women may have responded in a positive manner to the questions to present themselves in a socially desirable way. Also, some questions may have seemed leading and perhaps influenced how women responded. Third, their perceptions of their husbands' attitudes may not be accurate. Similarly, responses are all self-report and may not reflect true events. Finally, reliability and validity of the responses were not verified; however, the instrument was pilot tested.
These results have three specific implications. First, women must be informed about cervical cancer and how to prevent it. Awareness campaigns must provide accurate information so that women can make informed choices. Second, these campaigns must emphasize the importance and effectiveness of prevention in the form of regular cervical cancer checks. Thus, information is important, but must be combined with prescriptive information about how to take preventive action. Third, accessibility to screening must be improved. Findings from this study reveal that distance of the facility is a crucial determinant of whether women will access cervical cancer screening services.