Perceptions and beliefs of lay people from northern Uganda regarding surgery for diagnosis and treatment of cervical cancer.

OBJECTIVE: To explore perceptions and beliefs of people in a rural community in northern Uganda regarding surgery for the diagnosis and treatment of cervical cancer. The aim of the study was to inform interventions to reduce delay and improve timely diagnosis and prompt appropriate treatments for patients with symptoms of cervical cancer. METHODS: A semi-structured study guide informed by Kleinman's explanatory model for illness was used to collect data during 24 focus group discussions involving 175 men and women aged 18 to 59 years in Gulu, northern Uganda. Using thematic analysis, themes and subthemes were identified from the data through an iterative process and consensus among the authors. RESULTS: Surgery for diagnosis and management of cervical cancer was perceived as (1) appropriate when performed at early stage of cancer and by senior doctors, but (2) a potential catalyst for the spread of cancer and early death; and (3) a challenge to childbearing and motherhood as well as a source of distress to women and families if surgery involved removal of the uterus with subsequent permanent infertility. CONCLUSIONS: There are some negative perceptions about surgery for cervical cancer that may deter prompt help-seeking for symptoms. However, targeted messages for public awareness interventions to promote help-seeking can be built on the positive perceptions and beliefs that surgery could be curative when undertaken for early-stage cancer and by skilled doctors.

Excessive bleeding is a normal cleansing process: a qualitative study of postpartum haemorrhage among rural Uganda women.

BACKGROUND: Postpartum haemorrhage (PPH) remains the leading cause of maternal morbidity and mortality worldwide. The main strategy for preventing PPH is the use of uterotonic drugs given prophylactically by skilled health workers. However, in settings where many women still deliver at home without skilled attendants, uterotonics are often inaccessible. In such cases, women and their caregivers need to recognize PPH promptly so, as to seek expert care. For this reason, it is important to understand how women and their caregivers recognize PPH, as well as the actions they undertake to prevent and treat PPH in home births. Such knowledge can also inform programs aiming to make uterotonics accessible at the community level. METHODS: Between April and June 2012, a phenomenological study was carried out in a rural Ugandan district involving 15 in-depth interviews. Respondents were purposively sampled and included six women who had delivered at home in the past year and nine traditional birth attendants (TBAs). The interviews explored how PPH was recognized, its perceived causes, and the practices that respondents used in order to prevent or treat it. Phenomenological descriptive methodology was used to analyse the data. RESULTS: Bleeding after childbirth was considered to be a normal cleansing process, which if stopped or inhibited would lead to negative health consequences to the mother. Respondents used a range of criteria to recognize PPH: rate of blood flow, amount of blood (equivalent to two clenched fists), fainting, feeling thirsty, collapsing or losing consciousness immediately after birth. As a group, respondents seemed to correctly identify women at risk of PPH (those with twin pregnancies, high parity or prolonged labour), but many individuals did not know all the reasons. Respondents used cold drink, uterine massage and traditional medicine to treat PPH. CONCLUSION: The community viewed bleeding after childbirth as a normal process and their methods of determining excessive bleeding are imprecise and varied. This opens the door for intervention for reducing delays in the home diagnosis of PPH. This includes increasing awareness among TBAs, women and their families about the risk of death due to excessive bleeding in the immediate postpartum period.

Human Papillomavirus (HPV) Vaccination and Adolescent Girls' Knowledge and Sexuality in Western Uganda: A Comparative Cross-Sectional Study.

The purpose of the study was to investigate the influence of human papillomavirus (HPV) vaccination on adolescent girls' knowledge of HPV and HPV vaccine, perception of sexual risk and intentions for sexual debut. This cross-sectional comparative study was conducted in Ibanda and Mbarara districts. Data was collected using a standardized self-administered questionnaire and analyzed using the Statistical Package for the Social Sciences computer software. Univariate, bivariate, and logistic regression analyses were conducted with significance level set at p < .05. Results showed that HPV vaccination was associated with being knowledgeable (Crude OR: 5.26, CI: 2.32-11.93; p = 0.000). Vaccination against HPV did not predict perception of sexual risk. Knowledge was low (only 87/385 or 22.6% of vaccinated girls were knowledgeable), but predicted perception of a high sexual risk (Adjusted OR: 3.12, CI: 1.37-3.63; p = 0.008). HPV vaccination, knowledge and perceived sexual risk did not predict sexual behaviour intentions. High parental communication was associated with adolescent attitudes that support postponement of sexual debut in both bivariate and multiple regression analyses. In conclusion, findings of this study suggest that HPV vaccination is not likely to encourage adolescent sexual activity. Influence of knowledge on sexual behaviour intentions was not definitively explained. Prospective cohort studies were proposed to address the emerging questions.

Symptomatic presentation with cervical cancer in Uganda: a qualitative study assessing the pathways to diagnosis in a low-income country.

BACKGROUND: Symptomatic cervical cancer patients in low- and middle-income countries usually present with late stage disease and have poor survival. We explored the views of cervical cancer patients on their symptom appraisal and interpretations, and their help-seeking including lay consultations. METHODS: We conducted an in-depth interview study in two northern Ugandan hospitals. Theoretical models underpinned the study guide for data collection and analysis. We used thematic analysis techniques, informed by the theoretical concepts in the Model of Pathways to Treatment. Sub-themes and themes were identified through consensus among investigators. RESULTS: Eighteen women aged 35-56 years, recently diagnosed with cervical cancer were interviewed. Their first symptoms included abnormal vaginal bleeding, offensive vaginal discharge and lower abdominal pain. Most participants did not perceive themselves to be at risk for cervical cancer and they usually attributed the initial symptoms to normal bodily changes or common illnesses such as sexually transmitted diseases. Lay consultations with husbands, relatives and friends were common and often influenced decisions and timing for seeking care. Prompt help-seeking was frequently triggered by perceived life threatening symptoms such as heavy vaginal bleeding or lower abdominal pain; symptom burden sufficient to interfere with patients' work routines; and persistence of symptoms in spite of home-based treatments. Participants did not promptly seek care when they perceived symptoms as mild; interpreted symptoms as due to normal bodily changes e.g. menopause; and attributed symptoms to common illnesses they could self-manage. Their cancer diagnosis was often further delayed by long help-seeking processes including repeated consultations. Some healthcare professionals at private clinics and lower level health facilities failed to recognize symptoms of cervical cancer promptly therefore delayed referring women to the tertiary hospitals for diagnosis and treatment. CONCLUSION: Ugandan patients with symptomatic cervical cancer often misattribute their gynaecological symptoms, and experience long appraisal and help-seeking intervals. These findings can inform targeted interventions including community awareness campaigns about cervical cancer symptoms, and promote prompt help-seeking in Uganda and other low- and middle-income countries with high incidence and mortality from cervical cancer.

Understanding cervical cancer: an exploration of lay perceptions, beliefs and knowledge about cervical cancer among the Acholi in northern Uganda.

BACKGROUND: Cervical cancer is the most common cancer affecting women in Uganda; yet community understanding of the disease is limited. We explored community perceptions, beliefs and knowledge about the local names, causes, symptoms, course, treatment, and prognosis of cervical cancer in order to inform targeted interventions to promote early help-seeking. METHODS: Twenty four focus group discussions (FGD) with men and women aged 18 - 59 years and ten key informant interviews with persons aged ≥ 60 years were conducted at two sites in Gulu district between May and June 2012. A semi-structured interview guide informed by Kleinman's illness explanatory model and literature on community awareness of cervical cancer was used to collect data. Data analysis was supported with use of ATLAS.ti 6.1 in coding, organizing and tracking data segments. We used content analysis technique in data analysis and organised data into a structured format under distinct themes and categories. RESULTS: Cervical cancer was known by the local name "two remo", meaning "an illness that manifests with bleeding." Respondents believed that early onset of sexual activity, multiple male sexual partners and multi-parity cause cervical cancer. Respondents in half of FGDs also reported that use of condoms and family planning pills and injections cause cervical cancer. Symptoms of cervical cancer reported included vaginal bleeding, watery vaginal discharge and lower abdominal and waist pain. Respondents in most of the FGDs and key informants perceived cervical cancer as a chronic illness and that it can be treated with both modern and traditional medicines. The majority thought that cervical cancer treatment was supportive; the illness is not curable. CONCLUSIONS: While some lay beliefs about the causes of cervical cancer suggest some understanding of aetiology of the disease, other perceived causes particularly those related to use of family planning and condoms are potentially hurtful to public health. Awareness campaigns to promote early help-seeking for cervical cancer symptoms need to be culturally-sensitive and context-specific; and include messages on symptoms, risk factors, course, treatment and prognoses.

Caregivers' experiences with major depression concealed by physical illness in patients recruited from central Ugandan Primary Health Care Centers.

In this article, we present caregivers' grapples with major depression seen among their physically ill patients. A thematic analysis of 29 in-depth caregiver interviews identified four themes: (a) caregivers' perceptions of depression, (b) barriers to caregivers' focus on depression, (c) resources and opportunities for managing depression, and (d) caregivers' perspectives on consequences of depression. Patients' physical illnesses concealed depressive episodes. Caregivers could not apply the label of "depression" but enumerated its indicative features. Stigmatization of depression, common with other mental illnesses and poverty, undermined caregiving. Vital caregiving resources included caregivers' willingness to meet patients' basic needs, facilitating patients' access to health care, informal counseling of patients, and ensuring patients' spiritual nourishment. Caregivers' management of depression in physically ill patients was expensive, but they coped; however, caregiving was burdensome. Ongoing support should be given not only to patients but caregivers, as well. To provide appropriate care, caregivers deserve sensitization about depression in the context of physical illness.