Study area
This study was conducted in Lagos State, South-West Nigeria. Though the smallest in area of Nigeria's 36 states, Lagos State is arguably the most economically important state of the country [22]. Lagos has a population estimated at 21 million in 2016, which makes it the most populous state in Nigeria and the largest city in Africa [23] Pap smear services are only available in a few public healthcare facilities in Lagos. Some private hospitals and diagnostic centres also offer pap smear services to clients.
There has been a rapid development of slums in Lagos as a result of rapid urbanization and ruralurban migration [24]. Lagos has 192 identified slum communities [25]. Urban slums are settlements, neighbourhoods, or city regions that cannot provide the basic living conditions necessary for its inhabitants, to live in a safe and healthy environment [26]. The United Nations Human Settlements Programme (UN-HABITAT) defines a slum settlement as one that cannot provide any of the following basic living characteristics: Durable housing of a permanent nature that protects against extreme climate conditions; Sufficient living space, which means no more than three people sharing the same room; Easy access to safe water in sufficient amounts at an affordable price; Access to adequate sanitation in the form of a private or public toilet shared by a reasonable number of people; Security of tenure that prevents forced evictions [26].
Ago-Egun Bariga is a slum settlement located in Bariga Local Council Development Agency in the city of Lagos. The inhabitants are mainly of the Egun tribe with a few people of the Yoruba tribe. Ago-Egun Bariga is overcrowded and is lacking in basic social amenities. There is no pipe-borne water or drainage system. Human faeces are deposited into the water near the residence. The majority of the houses are built with wooden planks on the water surfaces. Others are old buildings made of mud-plastered walls and dilapidated zinc roofing.
Otto-Ilogbo extension is under the administration of the Lagos Mainland Local Government area. It is located around a large refuse dump located in between the Otto community and Ilogbo community, hence its name, Otto-Ilogbo extension. Its inhabitants are mainly Yoruba and Igbo petty traders and artisans who live freely amongst each other. There is no form of town planning in Otto-Ilogbo extension and the houses are numerous. Most of the houses are made of wooden planks and dilapidated zinc. There is no drainage system or pipe-borne water in the community and community members mostly practice open defecation. Otto-Ilogbo extension is grossly overcrowded.
The distance between the study community and the control community is about 20km by road. Both communities are located within different local governments, which are not contiguous in location. The commercial activities of both slum communities are also not directly related. This minimizes the chances of interaction between control and intervention arms, as well as spill-over effects of the intervention.
This study is a quasi-experimental controlled study with pre and post design, aimed at determining the effect of social marketing intervention on the knowledge, attitude and uptake of pap smear among women residing in an urban slum.
The study population consisted of women aged 2165years who reside in the two selected urban slums in LagosAgo-Egun Bariga (Intervention community) and Oto-Ilogbo extension (Control community). The inclusion criteria for the study were women who had resided in the slum for at least 1year and women that had been married/cohabiting/sexually active. The exclusion criteria were women who were too sick to attend the health education sessions/cervical cancer screening, women who were pregnant during the course of the study.
The study was based on the hypothesis that at post-intervention, the intervention group would have at least 20% (0.20) improvement in the knowledge, attitude, and uptake of Pap smear screening for cervical cancer [10]. The sample size was determined using the formula for the comparison of proportions [27].
$${text{n }} = frac{{left[ {{text{Z}}_{alpha } + {text{Z}}_{beta } } right]^{{2}} left{ {left[ {{text{P}}_{{1}} left( {{1} - {text{P}}_{{1}} } right)} right] , + , left[ {{text{P}}_{{2}} left( {{1} - {text{P}}_{{2}} } right)} right]} right}}}{{left[ {{text{P}}_{{1}} {-}{text{ P}}_{{2}} } right]^{{2}} }}$$
Prevalence (P2) of women who had undergone cervical cancer screening in a previous study was 13.3% [28].
The expected prevalence (P1) after the intervention was 33.3%. The calculated minimum sample size was 66 for each group. Because multistage sampling was employed, design effect was taken into consideration and the minimum sample size was multiplied by 2. The sample size then came to 132. After compensating for attrition, with an attrition rate of 30%, the sample size calculated was 188 for each group.
A multistage sampling method was used in selecting study participants. In the first stage, two slums from the list of slums in Lagos State were selected using a computer-generated table of random numbers. The sampling frame included all the 192 identified slum communities in Lagos. The first slum selected-Ago-Egun Bariga- was the intervention community while the second selectedOtto-Ilogbo extensionwas the control community.
In the second stage, each community was divided into five clusters based on the arrangement of houses and forty houses were selected from each cluster. The "spin the bottle" EPI-derived technique (a technique derived by EPI research Inc for cluster sampling in household surveys) was used in selecting the houses in each cluster [29]. The index house in each cluster was selected by spinning a bottle in the middle of the cluster. The bottle was observed to see where its tip points; the house whose front door was closest to the tip was the index house. The next house chosen was the one whose front door was closest to the index one.
In the third stage, where there was more than one eligible female in a house, the respondent was selected by simple random sampling by balloting. In the event that there was no eligible female in a selected house, it was excluded and the next house was selected.
Data was collected using interviewer-administered questionnaires. The questionnaire was adapted from previous studies. [12, 30,31,32] It contained questions on the socio-demographic characteristics of respondents, knowledge of cervical cancer (which include; ever heard of cervical cancer, symptoms and risk factors of cervical cancer, prevention of cervical cancerscreening and HPV vaccination), knowledge of pap smear (which include; ever heard of pap smear, how frequently the test should be done, women eligible for testing), attitude towards cervical cancer (which include Likert statements on perceived susceptibility to cervical cancer, perceived severity of cervical cancer and perception of screening), and uptake of pap smear. The questionnaires were pretested in another slum not used for the study and adjustments were made. Four trained female research assistants with post-secondary degrees collected data.
Focused group discussions (FGD) were conducted among women age 2165 in Ago Egun Barigathe intervention community prior to the commencement of the intervention. Homogenous groups of 810 women of similar age were used. The focused group discussion was aimed at gaining a deeper understanding of the womens perceptions about cervical cancer screening, barriers and recommendations, in order to aid the design and implementation of the social marketing intervention.
Findings from the qualitative survey guided the social marketing intervention. The respondents wanted the test to be free or largely subsidized and wanted female providers. Many said they will require the consent of their husbands to undergo the test. Also, the majority of the discussants wanted the test to be carried out in their community. The women suggested the use of a megaphone, SMS and health education sessions to promote the intervention.
Eight benchmarks describe the key concepts and principles of social marketing and include Customer orientation, Behavioural focus, Exchange, Developing insight, Competition analysis, Theory, Segmentation, and Methods Mix [33]. Customer orientation involves seeing things through the customers eyes. It involves understanding where the customer is starting from, their knowledge, attitudes and beliefs, and their social context [34]. Prior to the intervention, these were assessed using interviewer-administered questionnaires and focus group discussions. Behavioural focus implies that the intervention is focused on influencing specific behaviours, not just knowledge, attitudes, and beliefs [35]. In this regard, our study aimed to increase the uptake of pap smear, and not just increase knowledge and improve attitudes.
Exchange considers benefits and costs of adopting and maintaining a new behaviour; maximizes the benefits and minimizes the costs to create an attractive offer [35]. In this study, we provided pap smear services and explained the benefits of pap smear to the participants. We also reduced the costs by providing the pap smears free and making it easily accessible within the community. Spouses of the participants were also educated to reduce husbands disapproval (an intangible cost). Developing insight involves developing a deeper understanding of what is or is not likely to engage a target audience or motivate them in relation to a particular behaviour [33]. In our study, focus group discussions conducted before the intervention helped to understand potential enabling factors and barriers to change.
Competition analysis in social marketing leads to the identification of countervailing forces and the systematic development of strategies to reduce the impact of these external and internal competitive forces [33]. Some of the external countervailing forces we identified in our study were spouses disapproval, cost of the test, and distance to the testing site. These were addressed in the intervention. Internal countervailing forces included poor knowledge and attitudes towards cervical cancer screening and we addressed these by providing health education.
Theory involves using behavioural theories to understand target behaviour and inform the intervention [36]. The health belief model guided our intervention [37]. During the health education sessions, women received adequate information on the risk factors of cervical cancer so they can understand that all sexually active women are at risk of the disease and thus develop healthy perceptions of personal susceptibility (Perceived Susceptibility) [37]. The health education also provided information on the seriousness and consequences of cervical cancer in terms of symptoms and complications, ill-health and suffering, time lost from work, and economic difficulties (Perceived Severity) [37]. Our intervention also addressed the benefits of pap smear in detecting precancerous changes early, before cancerous changes manifest (Perceived Benefits).
We assessed barriers to cervical cancer screening using questionnaires and focus group discussions and addressed them. The perceived barriers identified included religious and cultural barriers, spouses disapproval, feeling embarrassed, and cost. The support of religious leaders, husbands, and traditional leaders was sought. The religious and traditional leaders helped promote the pap smear services by speaking at our health education sessions. The barrier of cost was addressed by making the pap smears free. Feelings of embarrassment were minimized by using only female service providers (Perceived Barriers). The cues provided in this study included SMS to remind the women about the date and time of the pap smears, and banners displayed strategically in the community in English, Yoruba, and Egun languages (Cues to Action). Undergoing pap smear does not require much effort from the client and we provided information on how to prepare for a pap smear test and what to expect in the health education sessions (Self-efficacy).
Segmentation involves assigning people to groups that exhibit similar characteristics, beliefs values, and behaviours in order to, develop specifically targeted interventions, designed to help them change behaviour [33]. In this study, we tried to identify segments of the population with similar characteristics. Using the socio-demographic characteristics, most of the women were married, of the Egun tribe, were of the Christian religion, had no formal education, and had low incomes. Hence they could not be segmented along these lines. Also, almost all the women had poor knowledge, poor attitude and all had not had cervical cancer screening in the past. The participants also had similar motivational factors e.g. cost, distance, and spousal support. The women were more similar in characteristics than different.
Product The providers were trained and supervised to be warm and receptive. They were trained to be courteous and to re-assure the women about the procedure and also to minimize discomfort during the procedure. Only female providers were recruited to provide pap smears as this was a recommendation from the focus group discussion. Bureaucracy, which is often the case in government hospitals where pap smear is provided was limited (Fig.1).
Social marketing framework
Price Pap smear services were offered free of charge. The clients did not need to pay for transportation, as the location of the services was within the community. This study had sensitization meetings for husbands to enable the spouses to understand the importance of pap smears and hence reduce disapproval (Fig.1).
Place Services were made available within the community (Fig.1). The place used was suitable and comfortable for the women and the procedure. Adequate privacy was ensured. Also, responses from the FGD had suggested a location within the community. The venue used was the clinic of a traditional birth attendant in the community, who is certified and registered with the State government ministry of health. The centre was re-painted to make it more appealing for the intervention.
Promotion Six health education sessions were organized for the women with each woman attending one health education session. A meeting was also carried out to educate their husbands on cervical cancer and pap smear. The health belief model guided the content of the health education sessions and information education communication (IEC) materialshandbills and banners. Contents of the health education included: a description of cervical cancer, its burden, risk factors, symptoms, complications, and prevention. The health education also included details on the Pap smear test, its importance, how frequently it should be done, and who should have it done. A brief description was also given of what to expect during the test (Fig.1).
As part of the promotion, community mobilization was carried out and three community mobilizes were sought amongst key people in the community who understood the local dialect. Religious clerics and community leaders also publicly showed support for the intervention through speeches. Information, Education, and communication (IEC) materials in form of handbills and banners were used and reminder SMSs were sent out periodically. The positioning statement for the social marketing intervention was Cervical Cancer Is Real, Get a Pap Smear Test Today. This was written in English, Egun, and Yoruba Languages and was boldly displayed on all banners, handbills, and t-shirts.
After the intervention, the same respondents who were interviewed at the beginning of the study were interviewed again using the same questionnaire to assess their knowledge, attitude, and uptake of Pap smear. The interviews were conducted for both the intervention group and the control group. Women in the control group had health education sessions on cervical cancer and free pap smears after the study, for ethical reasons.
The study duration was 7months from pre-intervention data collection to post-intervention data collection. The Health education sessions lasted for 6weeks and afterwards, pap smears were made available in the community for a period of 3months. There was a period of 4months between the health education sessions, and the post-intervention data collection.
Data entry and cleaning were done using Microsoft Excel 2010. Data was then imported and analysed using IBM SPSS Version 20.0 (Armonk, NY: IBM Corp). Stata Version 16 (College Station, TX: Stata Corp LLC) was used for difference in difference analysis. Categorical data were summarized using frequencies and proportions. Numerical data were summarized using means and standard deviations, median and interquartile range. Observations with incomplete data were excluded from analysis.
A scoring method was developed to quantify the respondents knowledge of cervical cancer and pap smear and also their attitude towards cervical cancer and pap smear. For the knowledge scoring, ten knowledge questions were scored. Knowledge questions scored include; ever heard of cervical cancer, symptoms of cervical cancer known, risk factors of cervical cancer known, if cervical cancer can be prevented, cervical cancer prevention measures known, ever heard of tests that detect cervical cancer early, does detecting cervical cancer early improve treatment outcome, type of cervical cancer screening tests known, ever heard of pap smear, and how often pap smear tests should be done. Correct responses were awarded a point each and incorrect responses no point. Some questions allowed multiple correct responses. The maximum attainable score was 32 while the lowest attainable score was 0. The mean knowledge score was calculated.
There were nine questions assessing attitudes of women towards cervical cancer and pap smear on a Likert scale. The questions were; Cervical cancer is a severe disease, I could be susceptible to cervical cancer, I cannot have cervical cancer because I dont have multiple sexual partners, I cannot have cervical cancer because I believe I am spiritually protected, Cervical cancer is a death sentence, Chances of curing cervical cancer are better when the disease is discovered at an early stage, Cervical cancer can be prevented from occurring, Cervical cancer screening is important, and I am comfortable with having a cervical cancer screening test. The highest score for each question was 5 while the lowest score was 1. The possible range of scores was 545. The mean attitude score was calculated.
Intergroup comparisons (intervention and control group comparisons) were made at baseline. Within-group comparison of the intervention group and the control group, before and after intervention was also done. Comparison of proportions between two groups was done using Pearsons chi-squared test or Fishers exact test as appropriate. For numerical data, independent sample T-test was used to compare across the two groups while paired T-test was used to compare each group before and after. Repeated measures analysis was also used to assess within and between group changes.
Difference-in-difference (DID) analysis was used to estimate intervention effects, adjusting for biases that could be the result from permanent differences between the groups (pre-existing differences), as well as biases from comparisons over time in the intervention group that could be the result of trends due to other causes of the outcome (time trends) [38]. The difference-in-difference is an early quasi-experimental strategy for estimating causal effects [39]. Difference-in-difference is a useful technique to use when randomization on the individual level is not possible [38]. The DID estimate is defined as the difference in the average outcome in the intervention group before and after the intervention minus the difference in the average outcome in the control group before and after the intervention [39]. DID analysis was done using linear random-effects regression with an interaction term between study arm and study period. [39]
The level of significance was set at 5%. Associations or differences were considered statistically significant if p values were less than or equal to 0.05.
Approval for this study was obtained from the health research and ethics committee of the Lagos University Teaching Hospital with approval number: ADM/DCST/HREC/APP/2028. Written informed consent was obtained. All methods were carried out in accordance with the relevant guidelines and regulations. e.g., the Declaration of Helsinki.
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Effect of social marketing on the knowledge, attitude, and uptake of pap smear among women residing in an urban slum in Lagos, Nigeria - BMC Women's...