A qualitative analysis of South African women's knowledge, attitudes and beliefs about HPV and cervical cancer prevention...

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JVAC-12146; No. of Pages 6

Vaccine xxx (2011) xxx–xxx

Contents lists available at ScienceDirect

Vaccine
journal homepage: www.elsevier.com/locate/vaccine

A qualitative analysis of South African women’s knowledge, attitudes, and beliefs
about HPV and cervical cancer prevention, vaccine awareness and acceptance,
and maternal-child communication about sexual health
Shelley A. Francis a,∗ , Michele Battle-Fisher b , Joan Liverpool c , Lauren Hipple d , Maghboehba Mosavel e ,
Soji Soogun f , Nokuthula Mofammere f
a
Division of Health Behavior and Health Promotion, College of Public Health, The Ohio State University, 174 W. 18th Avenue, 3138C Smith Lab, Columbus, OH 43210, United States
b
Master of Public Health Program, Boonshoft School of Medicine, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH 45435, United States
c
Deskan Institute, Stone Mountain, 424 Orchard Walk, Stone Mountain, GA 30087, United States
d
Lauren Hipple, The Laurel School, 10035 Hunting Drive, Brecksville, OH 44141, United States
e
Virginia Commonwealth University, School of Medicine, Department of Social McGuire Hall Annex (room L-23), PO Box 980149, 1112 E, Clay Street, Richmond, VA 23298, United
States
f
Consulting Rooms: No. 97–12th Avenue, Cnr. 12th Avenue & Rooseveldt Road, Alexandra 2090, South Africa

a r t i c l e i n f o a b s t r a c t

Article history: In South Africa, cervical cancer is the second leading cause of death among women. Black South Africa
Received 9 March 2011 women are disproportionately affected by cervical cancer and have one of the highest mortality rates
Received in revised form 8 July 2011 from this disease. Although the body of literature that examines HPV and cervical cancer prevention is
Accepted 25 July 2011
growing in the developing world; there is still a need for a better understanding of women’s knowledge
Available online xxx
and beliefs around HPV and cervical cancer prevention. Therefore, this formative study sought to examine
women’s attitudes, beliefs and knowledge of HPV and cervical cancer, HPV vaccine acceptance, maternal-
Keywords:
child communication about sexuality, and healthcare decision-making and gender roles within an urban
South Africa
HPV and cervical cancer prevention
community in South Africa.
Maternal attitudes Women ages 18–44 were recruited from an antenatal clinic in a Black township outside of Johan-
Communication nesburg during the fall of 2008. Twenty-four women participated in three focus groups. Findings
indicated that the women talked to their children about a variety of sexual health issues; had lim-
ited knowledge about HPV, cervical cancer, and the HPV vaccine. Women were interested in learning
more about the vaccine although they had reservations about the long-term affect; they reinforced
that grandmothers played a key role in a mother’s decisions’ about her child’s health, and supported
the idea that government should provide the HPV vaccine as part of the country’s immunization
program.
Our findings indicate the need to develop primary prevention strategies and materials that will pro-
vide women with basic cervical cancer prevention messages, including information about HPV, cervical
cancer, the HPV vaccine, screening, and how to talk to their children about these topics. Prevention
strategies should also consider the cultural context and the role that grandmothers play in the family
unit.
© 2011 Elsevier Ltd. All rights reserved.

1. Backround poverty, poor medical infrastructure, and low or limited access to
healthcare and other resources. For example, according to a recent
In most of the developing world (i.e., less industrialized), cervi- World Health Organization (WHO) report, Central and South Amer-
cal cancer remains the top cause of cancer-related deaths among ica, Eastern Africa, South Asia and Southeast Asia had the highest
women—a public health threat that is exacerbated by high rates of age-adjusted incidence rates of cervical cancer, ranging from 30 to
45 cases per 100,000 females [1].
In areas with few resources, there are a number of barriers to
cervical cancer screening. First, access to medical care may be lim-
∗ Corresponding author. Tel.: +1 614 292 4216; fax: +1 614 688 3533.
ited; second, women may lack education and knowledge about
E-mail addresses: sfrancis@cph.osu.edu (S.A. Francis), battle-fisher.1@osu.edu
(M. Battle-Fisher), liverpj@bellsouth.net (J. Liverpool), lhipple@laurelschool.org
the human papillomavirus (HPV), cervical cancer, and the impor-
(L. Hipple), mmosavel@vcu.edu (M. Mosavel), soj74@hotmail.com (S. Soogun). tance of regular screenings; third, women may lack the financial

0264-410X/$ – see front matter © 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.vaccine.2011.07.116

Please cite this article in press as: Francis SA, et al. A qualitative analysis of South African women’s knowledge, attitudes, and beliefs about HPV
and cervical cancer prevention, vaccine awareness and acceptance, and maternal-child communication about sexual health. Vaccine (2011),
doi:10.1016/j.vaccine.2011.07.116

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2 S.A. Francis et al. / Vaccine xxx (2011) xxx–xxx

resources to afford Pap exams; and, fourth, cultural and language 2. Materials and methods
barriers may limit women’s access to screenings and treatment
[2–4]. Women who do not have access to cervical cancer screenings 2.1. Study design and sample
(i.e., routine Pap tests) have a significantly higher risk of developing
cervical cancer [5]. Participants were recruited from an antenatal clinic in a Black
In developed (i.e., highly industrialized) countries, campaigns township within Johannesburg, South Africa, in the fall of 2008. To
against cervical cancer can attribute their success to the availabil- be eligible for the study, participants had to be female, be 18–44
ity and accessibility of trained clinicians and modern laboratories years old, read and speak English, and have at least one child. We
and equipment, along with sustained media campaigns targeting recruited 120 women to participate in the parent study, which
women and healthcare providers that promote regular Pap tests examined women’s attitudes, knowledge and practices around HPV
and routine medical screenings. These resources rarely exist in and cervical cancer [3]. Of those 120 women, 86 were eligible. As
developing countries, where the public health infrastructure may part of the parent study, eligible participants provided consent and
be limited and where women may lack basic health education and completed a brief survey that assessed their knowledge, attitudes,
often have to travel great distances for medical care [5,6]. A 2001 and beliefs about HPV, cervical cancer, screening practices, and HIV
WHO study found that no organized cervical cancer screening pro- prevention; their knowledge and acceptance of the HPV vaccine;
grams existed in many countries in Latin America, Sub-Saharan and maternal-child communication about sexual health. A com-
Africa or Asia [5]. munity health worker who had experience with community-based
In South Africa, a number of disparities exist in terms of research was hired as part of the study team. Additional details
incidence, mortality, and access to screening; cervical cancer is about the parent study’s methodology can be found in Francis et al.
the second leading cause of death among South African women, (2010).
with the highest mortality rate among black women aged 66–69 After completing the survey, all 86 participants were invited
years [2,3,7]. To address these disparities, South Africa’s Depart- to join focus groups. About 40 women expressed interest, but in
ment of Health identified cervical cancer as a national priority the end, only 24 agreed to participate and were scheduled for the
and introduced a policy in 2000 stating that all women who groups. Staff assigned participants for one of three focus groups,
access public services are entitled to three free Pap tests in their based on their availability. Reminder calls were made and text
lifetime, 10 years apart, starting at age 30 [7,8]. The program’s messages were sent one day before the group met, as well as
goal was to screen 70% of women over the age of 30 within 10 on the day of the group. Focus groups met at the same site (i.e.,
years of implementing the policy. Although the policy focuses medical clinic) where participants completed the brief survey. The
on women ages 30+, according to the WHO, fewer than 20% of groups were conducted in a private conference room within the
women ages 18–69 had been screened [9]. Findings were not clinic, and lasted about 90 minutes each; before the groups started,
presented for women ages 30+. Barriers to accessing this cov- participants provided written, informed consent (i.e., focus group
erage include lack of availability of services, lack of equipment, participants completed separate consent forms for the survey and
limited staff training, staff reluctance to provide pap smears, for the focus groups).
lack of laboratory services, and long turn-around time for lab The majority of focus group participants belonged to the Zulu
work [4,7]. Given these findings, it is clear that there is a dis- ethnic group. Introductory questions (e.g., what is your name?
connect with the screening policy, its implementation, access to How many children you have?) were asked in English, while the
and availability of services, and women’s knowledge and prac- remaining questions were asked in both English and Zulu to facili-
tices. tate comprehension. Participants were assured that all data would
In the last seven years, a growing body of literature has remain confidential and that the anonymity of answers would be
developed, worldwide, around women’s and parents’ knowledge, maintained. Each focus group was led by one facilitator. A second
attitudes, and beliefs about HPV and cervical cancer, as well as staff member took notes and assisted with group management,
knowledge and acceptance of the HPV vaccine [2,3,6,7,10]. Stud- while the third staff member, the community health worker, trans-
ies have consistently found that parents had limited knowledge lated. The focus groups were digitally recorded for accuracy.
about cervical cancer and HPV, but that they were willing to vac- When the focus groups ended, participants received a lunch
cinate their children. While findings from studies that assessed or a light dinner. Travel vouchers were provided, and partici-
HPV and cervical cancer prevention among women in devel- pants were given ZAR 50 ($5 US) to thank them for their time.
oping countries found that participants had limited knowledge The study was approved by institutional review boards at both
about HPV, cervical cancer, and Pap exams, few participants the University of the Witswaterandt and Case Western Reserve
reported having had a Pap exam or had limited access to pre- University.
ventive screenings, and participants were not familiar with the
term “cervix” but used the term “womb” instead when discussing 2.2. Data analysis
health problems of the cervix [2–4,11]. Many studies have empha-
sized the need for regular screening and for improving access Digital records were transcribed by the study staff. Hand-
to information about HPV and cervical cancer. However, fewer written notes were used to supplement the digital records. The
empirical studies have taken place in developing countries, where analyst triangulation technique was used to analyze focus group
additional challenges may exist. Although prevention education data. This technique uses multiple analysts to review findings
should be a major component of cervical cancer awareness pro- [12]. Using grounded theory, recurring themes were identified
grams, the advent of vaccines to prevent cervical cancer and and grouped according to grand thematic areas [13,14]. Com-
HPV provides the unique opportunity to develop both prevention ments were identified as recurring if two or more participants
education strategies along with providing prophylaxis options to gave the same response. It was important to use at least three
reduce morbidity and mortality. Therefore, this formative study reviewers (one South African who was not part of the study
sought to examine women’s attitudes, knowledge, and beliefs team, one staff member, and a reviewer who did not partici-
around HPV and cervical cancer prevention, vaccine awareness pate in the study administration) to assure that themes would
and acceptance, and maternal-child communication about STDs be independently validated. One reviewer had not worked in
and sexual health within an urban community in Johannesburg, the cultural context. As a result, she flagged responses or com-
South Africa. ments that related to cultural values or norms and consulted

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S.A. Francis et al. / Vaccine xxx (2011) xxx–xxx 3

with the study PI (Francis) about how best to interpret the com- Participant in focus group 3: “I tell him he must use a condom
ments. (later on when he is older). I tell him when he does something
Themes were analyzed for each question within individual focus wrong”.
group session as well as across the three focus group sessions. The
Participant in focus group 3: “[Premarital sex is] bad because
data was coded under the following themes:
sometimes you [daughter] end up having an unexpected preg-
nancy or even with an STD and not knowing what to do or where
• General nature of communication with children (e.g., what types
to go for help. So, I think it is not [refers to the difference in how
of things do you and your child discuss) sexually active males and females are viewed, the majority of
• Attitudes and beliefs about sexual intercourse before marriage
participant believe males and females are viewed differently],
• Healthcare decision making
because once they [the male] discover that you are pregnant,
• Sources of information about HPV, cervical cancer
they will go and find someone that is not pregnant. They don’t
• Attitudes about the HPV vaccine
take their responsibilities.”
• Male-female social and cultural dynamics
• Maternal perception of children’s risk for HPV and cervical cancer Next, participants explored the role of parents (mother, father,
• Maternal-child communication about STDs and sexual health and extended family) in making healthcare decisions.
• Role of media in health decisions
3.2. Healthcare decision-making and gender roles
For the purpose of this manuscript, the analysis and results focus
on the following four themes: Participants were asked who makes the health-related decisions
in their households. The majority of participants agreed that the
• maternal-child communication about sexuality responsibility for soliciting care for children lies with women, with
• healthcare decision making and gender roles mothers and other female family members taking the lead in the
• knowledge and understanding of HPV and cervical cancer healthcare decisions. They said that fathers were generally absent
• HPV vaccine acceptance from the process. In addition, all participants agreed that decisions
about their children’s health depended on access to medical care.
Quotations were selected that best illustrated the themes of Participants noted that medical care was often sought as a curative
interest. action and there was overwhelming agreement across groups that
participants sought care when the children were ill. Other sources
for negotiating healthcare decisions included seeking the coun-
3. Results
sel of Sangomas or other traditional medicine practitioners and
Western medicine clinicians. However, it was unclear what the
Three focus groups were conducted, with a total of 24 partici-
usual distribution of such visits between Sangomas and western
pants. All participants had at least some education, with 50% having
medicine clinics were. When asked specifically about vaccination
completed secondary school (i.e., high school equivalent); all had
decisions, the majority of participants across two focus groups said
at least one child, 53% had a daughter; and 87% lacked medical
that fathers had only limited involvement, though one mother said
aid (equivalent of medical insurance in U.S.). At the beginning of
she had to ask the father for permission to vaccinate their daugh-
the focus group, the lead facilitator asked participants to intro-
ter. Participants made the following comments about the role of
duce themselves and to share information about their children:
parents and extended family in making healthcare decisions:
their biological sex, their ages, and the activities they enjoy. These
introductory questions were asked before the core focus group Participant in group 3: “Most of the time it is the mother, but you
questions. also get advice from grannies and older people in the community
and the clinic.”
3.1. Maternal-child communication and sexuality Participant in group 1 (on fathers’ involvement in deciding
whether to vaccinate a child): “Not all of them. Some like to
Participants were asked what issues they discussed with their know how their children are or even protect them. So, I would
children. The issues they identified included recreation/play, safety, think that you should let them be informed about their children.
self-esteem, and education. The majority of participants in two of Yeah, and I would ask his permission [to vaccinate our child].”
the groups identified safe sex as a topic of discussion with sons
and daughters without prompting while participants in the third Next, we explored participants’ knowledge and understanding
group did not mention sex as a discussion point until prompted by of HPV and cervical cancer.
the facilitator. Culture and gender norms became most apparent in
the responses to issues of sexual health. For example, women with 3.3. Understanding of HPV and cervical cancer
older children (across focus groups) said that there was a double
standard in their culture—it was accepted that boys engage in sex- The participants’ foremost desire was to care as best they could
ual activity, while this behavior was frowned upon for girls. The vast for their children based on the availability of medical services
majority (greater than 75%) of participants said that girls face bur- and clinics in their community. However, most participants lacked
dens and social stigma, including pregnancy that boys in the culture knowledge about HPV and cervical cancer, though three partic-
do not face. Condom use was discussed but only with male children. ipants were quite knowledgeable about these issues. When the
There was a consensus across groups that religion or religious val- discussion turned to the HPV vaccine—or, as many participants
ues clearly state that premarital sex is wrong, but as one participant put it, the “cancer of the womb vaccination”—an overall lack of
said, “it is a reality that must be dealt with at some point.” The understanding of cervical cancer became apparent. The majority of
majority of participants agreed that girls bear the responsibility for participants stressed that they wanted their children to be healthy
or burden of the negative consequences of premarital sex, includ- but that they knew little about the etiology of HPV and the “cancer
ing diminished opportunities for marriage and lack of male support of the womb” or cervical cancer. However, one of the participants
in childrearing. The following quotes highlight two participants’ who demonstrated advanced knowledge of HPV shared the follow-
perception about gender roles and premarital sexual activity: ing information:

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Participant in group 2: “I have heard of it [HPV]. I know it is in the 1) Participants talked to their children about a variety of sexual
cervix. It also can produce cervical cancer. Low HPV can cause health issues. However, they identified differences in gender role
complications, but it’s the high HPV that can lead to cervical expectations for adolescents who engage in premarital sexual
cancer.” activity, with girls facing the “burden” of pregnancy.
2) The majority of participants agreed that mothers and/or grand-
Other participants shared their concern about their lack of
mothers played a key role in making healthcare decisions for
knowledge about HPV and cervical cancer. But they also identified
their children, with limited involvement by fathers.
the importance of health education and health promotion efforts.
3) The majority of participants knew little about HPV, cervical can-
They said that they needed more information about HPV and cer-
cer, and the HPV vaccine, and they expressed interest in learning
vical cancer and would like information on how to talk to their
more about these topics.
children about these issues to keep them safe and healthy.
4) Participants agreed that vaccinations would keep their
Participant in group 3: “What I know about this HPV is that it is a children healthy, but they worried about long-term side
sexually transmitted disease and it is terrible. But controllable.” effects and
Participant in group 1: “They say they are so anxious to know 5) Most participants thought the government should offer the vac-
about this HPV because no one knows about it, and for most of cine for free as part of the country’s immunization program,
them, this is the first time they have heard about it.” though a small number of participants suggested that individu-
als should pay a portion of the vaccine’s cost.
Next, participants discussed the HPV vaccine and vaccine accep-
tance.
The qualitative findings from this study build on the quantita-
tive work of the parent study [3]. The use of qualitative methods in
3.4. Vaccine acceptance formative research is becoming more accepted as a mode of scien-
tific inquiry. It may be viewed as a vital precursor to a discussion of
The discussion about vaccines framed two main areas: tradi- evidence-based research in the future. For instance, Weingarten
tional vaccines (e.g., for measles, polio, etc.) and the new HPV (2004) posits that to uncover perceptions and beliefs at such a
vaccine, Gardasil or Cervarix. When asked about vaccine efficacy in micro-level distinction in the women’s voices becomes most pos-
general, most participants agreed that childhood vaccinations are sible with qualitative assessment [15]. Moreover, Aujoulat et al.
a proper defense against preventable disease. However, a minority (2007) found in using qualitative methods a linkage of social agency
of participants spoke of the vicarious pain they felt in witnessing to social determinations of health being explored is formed [15].
their children’s discomfort during vaccination. Central to this study was the ability to provide women with a safe
Staff explained the purpose of the HPV vaccine to participants environment in which to speak to their unique “embodied” experi-
and said that although the vaccine was approved for use in South ences and gain support from other women with a common cultural
Africa, it was not yet currently available. The next set of questions background [16,17].
examined barriers to getting the vaccine and ways to overcome Our findings are consistent with McFarland’s previous empir-
them. One participant mentioned concern for what was in the vac- ical work, which found that women in Sub-Saharan African had
cine [e.g., concerned that vaccine may contain harmful ingredients], limited knowledge of HPV, cervical cancer, and Pap exams. Our
while another participant worried about the long term side effects work also supports previous work by Wood et al. (1997), in
for the HPV vaccine because the local health department would only that our participants were not familiar with the term cervix
provide care that was “approved and beneficial.” One participant or cervical cancer but instead used the term “womb” when
said that child abuse was a problem in her community and that the referring to health problems specific to this reproductive area
HPV vaccine might protect girls if they were forced to have sex; sev- [11]. This study also found that fathers played a limited role in
eral other participants agreed. The vaccine’s cost did not come up parental healthcare decision-making; participants instead sought
as a major concern; parents were more worried about keeping their counsel from their extended female, family/support systems.
children safe, and they were interested in getting the vaccine if it However, they also said that they consulted with health-
could keep their children from getting cancer. However, the major- care providers, including both Western-trained clinicians and
ity of participants agreed that the government should provide the Sangomas.
vaccine for free, because it provided other vaccines for free as part In terms of vaccine acceptance, participants had limited knowl-
of the country’s immunization program. On the other hand, several edge and understanding of the HPV vaccine and expressed some
participants suggested that individuals should pay a small portion concern in not having the adequate knowledge required to talk to
of the cost of the vaccine. The majority of participants agreed that their children about HPV and cervical cancer prevention. While
having the vaccine would protect their child because when their participants thought vaccines in general were a good primary
children are not around them they may not know what they are prevention strategy, they were interested in getting additional
doing so they want to keep them safe. Another participant noted information about the HPV vaccine. Although their knowledge of
that comprehension of the disease involved communication with the vaccine was limited, once staff explained the purpose of the
health providers. Although some participants expressed concern vaccine and that it was licensed in the country but not yet avail-
about the vaccine, the majority shared the following comments able for purchase, the participants overwhelmingly expressed a
about vaccine acceptance: desire to have their children vaccinated, citing the need to keep
Translator on behalf of participant: “As long as someone explains their children safe and protect them.
what the shot is for and how it will help her child, she is OK with Of particular interest is their emphasis on child abuse. Partic-
it.” ipants worried that young females were particularly at risk for
molestation and/or rape, and said that access to the vaccine might
4. Discussion reduce their chance of exposure to HPV if they were forced to
have unprotected sex. Other studies in South Africa have identi-
This is one of the first qualitative studies to examine knowledge fied similar concerns about violence against young females. Nelson
of and attitudes about HPV and cervical cancer, as well as knowl- et al. (2010) interviewed Sangomas to assess their knowledge and
edge and acceptance of the HPV vaccine, among black women in an attitudes about HPV and cervical cancer prevention as well as the
urban setting in South Africa. Key findings from this study include: role of traditional healers and Western clinicians in cervical cancer

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prevention [2]. Findings indicate that Sangomas were concerned 6. Conclusion
about domestic violence particularly sexual assaults of young
girls and the Sangomas commented that the HPV vaccine might The current study highlights some of the social and cultural
be able to further protect young females who are assaulted or issues that women face in terms of gender roles and addressing
raped. Mosavel et al. (2005) used a community-based participatory their children’s health as well as their own sexual health. Our find-
approach to identify local priorities around cervical cancer preven- ings indicate the need to develop primary prevention strategies and
tion in an urban community in Cape Town, South Africa [10]. One of materials that will inform women about the basics of cervical can-
the issues that the community identified was that they wanted to cer prevention, including information about HPV, cervical cancer,
focus not just on preventing cervical cancer but also on reproduc- the HPV vaccine, screening, and how to talk to their children about
tive health in general and the multiple social issues associated with these topics. In addition, point-of-use and dissemination strate-
it, including HIV/AIDS, STDs, cervical health, poverty, and sexual gies should be further explored to assess which groups to target
violence. for HPV and cervical cancer prevention (e.g., mothers, grandmoth-
Although the HPV vaccine is currently available in South Africa, ers, adolescents) and to identify where to engage them (e.g., in the
the cost is quite prohibitive (R700 per shot) [equivalent of $100 community, in clinics, at schools). However, cultural ascriptions
US/shot] to individuals with limited resources e.g., domestic work- and gender norms should be taken into consideration in developing
ers monthly salary is US $100 [18]. Therefore, in the short term, any prevention programs and/or messages. For instance, given the
it might be best to emphasize the development and imple- women’s reliance on their extended families in making healthcare
mentation of effective primary preventive strategies. Potential decisions, there may be a need to develop multigenerational mate-
primary prevention strategies might include: (1) developing cul- rials. A multigenerational strategy is particularly important given
turally appropriate, multigenerational educational materials and that Black women ages 66–69 have South Africa’s highest cervical
messages for girls, mothers, and grandmothers; (2) developing cul- cancer morbidity. In addition, women need to be informed about
turally appropriate materials and/or training for women on how to the availability of three lifetime Pap exams and they need to be
talk to their children and teens about sexual health, and; (3) devel- informed about how to access this service. In summary, although
oping effective strategies for disseminating messages regarding this study provides a better understanding of where to focus pre-
the screening policy and Pap exams. However, secondary preven- vention and educational efforts, future primary prevention efforts
tion strategies (e.g., screening and treatment for HPV and cervical should aim to (1) educate women including their extended female
cancer) need to be effectively and efficiently coordinated. The family members about HPV, the vaccine, and cervical cancer pre-
South African government has taken the first step to address cer- vention, (2) provide women with information and training on how
vical cancer morbidity and mortality. However, in order for the to talk with their children about these topics, (3) address women’s
country’s cervical cancer prevention strategy to succeed, women concerns about the vaccine’s efficacy and long-term effects, (4)
need to have access to prevention education, screening, treatment, increase access to screening and treatment, and (5) prevention
and obtain the knowledge needed to make informed reproductive programs should include women, from the target population, in
health decisions. tailoring HPV and cervical cancer prevention messages.

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doi:10.1016/j.vaccine.2011.07.116

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