Early detection of cervical cancer in western Kenya: determinants of healthcare providers performing a gynaecological examination for abnormal vaginal discharge or bleeding

Abstract

Background: In western Kenya, women often present with late-stage cervical cancer despite prior contact with the health care system. The aim of this study was to predict primary health care providers' behaviour in examining women who present with abnormal discharge or bleeding.

Methods: This was a cross-sectional survey using the theory of planned behaviour (TPB). A sample of primary health care practitioners in western Kenya completed a 59-item questionnaire. Structural equation modelling was used to identify the determinants of providers' intention to perform a gynaecological examination. Bivariate analysis was conducted to investigate the relationship between the external variables and intention.

Results: Direct measures of subjective norms (DMSN), direct measures of perceived behavioural control (DMPBC), and indirect measures of attitude predicted the intention to examine patients. Negative attitudes toward examining women had a suppressor effect on the prediction of health workers' intentions. However, the predictors of intention with the highest coefficients were the external variables being a nurse (β = 0.32) as opposed to a clinical officer and workload of attending less than 50 patients per day (β = 0.56). In bivariate analysis with intention to perform a gynaecological examination, there was no evidence that working experience, being female, having a lower workload, or being a private practitioner were associated with a higher intention to conduct vaginal examinations. Clinical officers and nurses were equally likely to examine women.

Conclusions: The TPB is a suitable theoretical basis to predict the intention to perform a gynaecological examination. Overall, the model predicted 47% of the variation in health care providers' intention to examine women who present with recurrent vaginal bleeding or discharge. Direct subjective norms (health provider's conformity with what their colleagues do or expect them to do), PBC (providers need to feel competent and confident in performing examinations in women), and negative attitudes toward conducting vaginal examination accounted for the most variance. External variables in this study also contributed to the overall variance. As the model in this study could not explain 53% of the variance, investigating other external variables that influence the intention to examine women should be undertaken.

Keywords: Abnormal uterine bleeding; Cervical cancer; Early detection; Health care providers; Health care seeking delays; Kenya; Primary health care; Theory of planned behaviour.

Fig. 1

Theory of Planned Behaviour (Ajzen, [27]). Legend: Three variables (attitudes; subjective norms; and perceived behavioural control) which the theory suggests will predict the intention to perform a behaviour. Intentions are the precursors of behaviour. External variables - these might influence intention (from literature). The theory of planned behaviour applies to behaviour that one strives to perform. The intention to achieve a goal (in this case to perform a gynecological examination) is not the same as to actually perform it. Attitude is one of the three variables that the theory suggests predicts intention. Attitude towards the act (performance) is the precursor (mental event) of intention. Intention is the pathway attitudes take towards actually performing the act/behaviour (observable action). But intention is not action. Intention is what immediately precedes the behavior: someone has the intention to perform a specific behaviour, and shortly thereafter, the behaviour is performed, unless some unexpected situations occur. Attitude is more distal and a more ‘global’ concept. In the Theory of Planned Behaviour, the expectation of what a certain behaviour will result in and the value attributed to that expected result, determine the attitude. E.g.: when a gynaecologist expects that performing a medical exam in a woman with vaginal complaints will help this woman, the gynaecologist has a positive expectation of performing that exam. When the gynaecologist expects that doing a medical exam will make no difference, or even harm the woman, he/she has a negative expectation of performing that exam. When the gynaecologist also values a favourable outcome for the woman as important, he/she has a positive value. A positive expectation combined with a positive value, will lead to a positive attitude, which in turn, will lead to a bigger chance that he/she will have the intention to perform a medical exam

Fig. 2

Graphic representation of the SEM exploring the relationships among the predictor variables of the TPB and intention to do a gynaecological examination. Legend: Ovals indicate latent constructs; rectangles indicate observed constructs. Error values associated with each are indicated as small circles with the letter “e” inside them. Standard coefficients are shown above the paths between constructs showing positive and negative associations. Factor loadings are indicated between latent constructs and the indicators. The variation explained in the model by the six latent constructs, r², is provided. The direction of the coefficients – positive or negative, show whether the relationship between the predictor and outcome is positive or negative and the number indicates the degree to which the predictor affects the outcome. Bold arrows show variation in latent variables whereas dashed arrows show variation in the intention to perform a gynaecological examination. Standardized effect sizes and their statistical significance (* p < 0.05, ** p < 0.01, *** p < 0.001) are shown. DMA, direct measures of attitude; DMSN, direct measures of subjective norm; DMPBC, direct measure of perceived behavioural control; +ATT, positive measures of attitude (indirect); −ATT, negative measures of attitude (indirect); SN, indirect measures of subjective norm; PBC, indirect measures of perceived behavioural control