ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6                                                                         ...
ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 62                                                         S.A. Francis et...
ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6                                                          S.A. Francis et...
ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 64                                                         S.A. Francis et...
ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6                                                       S.A. Francis et al...
ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 66                                                              S.A. Franc...
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A qualitative analysis of South African women's knowledge, attitudes and beliefs about HPV and cervical cancer prevention...


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Francis, S., Battle-Fisher, M.#, Liverpool, J., Hipple, L., Mosavel, M., Shogun, S.,
& Mofammere, M. (2011) 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, 29, 8760-8765.

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

  1. 1. ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6 Vaccine xxx (2011) xxx–xxx Contents lists available at ScienceDirect Vaccine journal homepage: qualitative analysis of South African women’s knowledge, attitudes, and beliefsabout HPV and cervical cancer prevention, vaccine awareness and acceptance,and maternal-child communication about sexual healthShelley A. Francis a,∗ , Michele Battle-Fisher b , Joan Liverpool c , Lauren Hipple d , Maghboehba Mosavel e ,Soji Soogun f , Nokuthula Mofammere fa 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 Statesb Master of Public Health Program, Boonshoft School of Medicine, Wright State University, 3640 Colonel Glenn Hwy., Dayton, OH 45435, United Statesc Deskan Institute, Stone Mountain, 424 Orchard Walk, Stone Mountain, GA 30087, United Statesd Lauren Hipple, The Laurel School, 10035 Hunting Drive, Brecksville, OH 44141, United Statese 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, UnitedStatesf Consulting Rooms: No. 97–12th Avenue, Cnr. 12th Avenue & Rooseveldt Road, Alexandra 2090, South Africaa r t i c l e i n f o a b s t r a c tArticle history: In South Africa, cervical cancer is the second leading cause of death among women. Black South AfricaReceived 9 March 2011 women are disproportionately affected by cervical cancer and have one of the highest mortality ratesReceived in revised form 8 July 2011 from this disease. Although the body of literature that examines HPV and cervical cancer prevention isAccepted 25 July 2011 growing in the developing world; there is still a need for a better understanding of women’s knowledgeAvailable 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 urbanSouth AfricaHPV 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 highestwomen—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: (S.A. Francis), Battle-Fisher), (J. Liverpool), the human papillomavirus (HPV), cervical cancer, and the impor-(L. Hipple), (M. Mosavel), (S. Soogun). tance of regular screenings; third, women may lack the financial0264-410X/$ – 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
  2. 2. ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 62 S.A. Francis et al. / Vaccine xxx (2011) xxx–xxxresources to afford Pap exams; and, fourth, cultural and language 2. Materials and methodsbarriers 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 developingcervical 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. Toagainst cervical cancer can attribute their success to the availabil- be eligible for the study, participants had to be female, be 18–44ity and accessibility of trained clinicians and modern laboratories years old, read and speak English, and have at least one child. Weand equipment, along with sustained media campaigns targeting recruited 120 women to participate in the parent study, whichwomen and healthcare providers that promote regular Pap tests examined women’s attitudes, knowledge and practices around HPVand routine medical screenings. These resources rarely exist in and cervical cancer [3]. Of those 120 women, 86 were eligible. Asdeveloping countries, where the public health infrastructure may part of the parent study, eligible participants provided consent andbe 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 HIVWHO 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 detailsincidence, 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 invitedyears [2,3,7]. To address these disparities, South Africa’s Depart- to join focus groups. About 40 women expressed interest, but inment of Health identified cervical cancer as a national priority the end, only 24 agreed to participate and were scheduled for theand 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 textlifetime, 10 years apart, starting at age 30 [7,8]. The program’s messages were sent one day before the group met, as well asgoal 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. Theon women ages 30+, according to the WHO, fewer than 20% of groups were conducted in a private conference room within thewomen 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 grouperage include lack of availability of services, lack of equipment, participants completed separate consent forms for the survey andlimited 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 Zuluwork [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 theand 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 bedeveloped, worldwide, around women’s and parents’ knowledge, maintained. Each focus group was led by one facilitator. A secondattitudes, 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 lunchcinate 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 bothabout HPV, cervical cancer, and Pap exams, few participants the University of the Witswaterandt and Case Western Reservereported having had a Pap exam or had limited access to pre- University.ventive screenings, and participants were not familiar with theterm “cervix” but used the term “womb” instead when discussing 2.2. Data analysishealth 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. Theempirical studies have taken place in developing countries, where analyst triangulation technique was used to analyze focus groupadditional challenges may exist. Although prevention education data. This technique uses multiple analysts to review findingsshould be a major component of cervical cancer awareness pro- [12]. Using grounded theory, recurring themes were identifiedgrams, 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 participantseducation strategies along with providing prophylaxis options to gave the same response. It was important to use at least threereduce morbidity and mortality. Therefore, this formative study reviewers (one South African who was not part of the studysought 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 wouldand acceptance, and maternal-child communication about STDs be independently validated. One reviewer had not worked inand 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 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
  3. 3. ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6 S.A. Francis et al. / Vaccine xxx (2011) xxx–xxx 3with the study PI (Francis) about how best to interpret the com- Participant in focus group 3: “I tell him he must use a condomments. (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 becausedata 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 focuson 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 curativeinterest. 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 westernpants. All participants had at least some education, with 50% having medicine clinics were. When asked specifically about vaccinationcompleted secondary school (i.e., high school equivalent); all had decisions, the majority of participants across two focus groups saidat least one child, 53% had a daughter; and 87% lacked medical that fathers had only limited involvement, though one mother saidaid (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 ofduce 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. Theseintroductory questions were asked before the core focus group Participant in group 3: “Most of the time it is the mother, but youquestions. 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 wouldchildren. 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 sonsand daughters without prompting while participants in the third Next, we explored participants’ knowledge and understandinggroup 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 inthe responses to issues of sexual health. For example, women with 3.3. Understanding of HPV and cervical cancerolder children (across focus groups) said that there was a doublestandard in their culture—it was accepted that boys engage in sex- The participants’ foremost desire was to care as best they couldual activity, while this behavior was frowned upon for girls. The vast for their children based on the availability of medical servicesmajority (greater than 75%) of participants said that girls face bur- and clinics in their community. However, most participants lackeddens 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 theThere was a consensus across groups that religion or religious val- discussion turned to the HPV vaccine—or, as many participantsues clearly state that premarital sex is wrong, but as one participant put it, the “cancer of the womb vaccination”—an overall lack ofsaid, “it is a reality that must be dealt with at some point.” The understanding of cervical cancer became apparent. The majority ofmajority of participants agreed that girls bear the responsibility for participants stressed that they wanted their children to be healthyor burden of the negative consequences of premarital sex, includ- but that they knew little about the etiology of HPV and the “cancering diminished opportunities for marriage and lack of male support of the womb” or cervical cancer. However, one of the participantsin 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: 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
  4. 4. ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 64 S.A. Francis et al. / Vaccine xxx (2011) xxx–xxx 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 forknowledge 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 learningvical 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 in3.4. 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, Weingartentional vaccines (e.g., for measles, polio, etc.) and the new HPV (2004) posits that to uncover perceptions and beliefs at such avaccine, 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 agencyof 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 culturalAfrica, 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 hadcine [e.g., concerned that vaccine may contain harmful ingredients], limited knowledge of HPV, cervical cancer, and Pap exams. Ourwhile another participant worried about the long term side effects work also supports previous work by Wood et al. (1997), infor the HPV vaccine because the local health department would only that our participants were not familiar with the term cervixprovide care that was “approved and beneficial.” One participant or cervical cancer but instead used the term “womb” whensaid that child abuse was a problem in her community and that the referring to health problems specific to this reproductive areaHPV vaccine might protect girls if they were forced to have sex; sev- [11]. This study also found that fathers played a limited role ineral other participants agreed. The vaccine’s cost did not come up parental healthcare decision-making; participants instead soughtas 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 andity 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 someparticipants suggested that individuals should pay a small portion concern in not having the adequate knowledge required to talk toof the cost of the vaccine. The majority of participants agreed that their children about HPV and cervical cancer prevention. Whilehaving the vaccine would protect their child because when their participants thought vaccines in general were a good primarychildren are not around them they may not know what they are prevention strategy, they were interested in getting additionaldoing so they want to keep them safe. Another participant noted information about the HPV vaccine. Although their knowledge ofthat comprehension of the disease involved communication with the vaccine was limited, once staff explained the purpose of thehealth 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 aabout 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 might4. 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. Nelsonof and attitudes about HPV and cervical cancer, as well as knowl- et al. (2010) interviewed Sangomas to assess their knowledge andedge and acceptance of the HPV vaccine, among black women in an attitudes about HPV and cervical cancer prevention as well as theurban setting in South Africa. Key findings from this study include: role of traditional healers and Western clinicians in cervical cancer 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
  5. 5. ARTICLE IN PRESSG ModelJVAC-12146; No. of Pages 6 S.A. Francis et al. / Vaccine xxx (2011) xxx–xxx 5prevention [2]. Findings indicate that Sangomas were concerned 6. Conclusionabout domestic violence particularly sexual assaults of younggirls and the Sangomas commented that the HPV vaccine might The current study highlights some of the social and culturalbe able to further protect young females who are assaulted or issues that women face in terms of gender roles and addressingraped. 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 andtion 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 abouttive 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 targetviolence. 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 thethe cost is quite prohibitive (R700 per shot) [equivalent of $100 community, in clinics, at schools). However, cultural ascriptionsUS/shot] to individuals with limited resources e.g., domestic work- and gender norms should be taken into consideration in developingers monthly salary is US $100 [18]. Therefore, in the short term, any prevention programs and/or messages. For instance, given theit might be best to emphasize the development and imple- women’s reliance on their extended families in making healthcarementation 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 giventurally appropriate, multigenerational educational materials and that Black women ages 66–69 have South Africa’s highest cervicalmessages for girls, mothers, and grandmothers; (2) developing cul- cancer morbidity. In addition, women need to be informed aboutturally appropriate materials and/or training for women on how to the availability of three lifetime Pap exams and they need to betalk to their children and teens about sexual health, and; (3) devel- informed about how to access this service. In summary, althoughoping 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 effortstion strategies (e.g., screening and treatment for HPV and cervical should aim to (1) educate women including their extended femalecancer) 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 howvical cancer morbidity and mortality. However, in order for the to talk with their children about these topics, (3) address women’scountry’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) preventionand obtain the knowledge needed to make informed reproductive programs should include women, from the target population, inhealth decisions. tailoring HPV and cervical cancer prevention messages. References5. Strengths and limitations [1] World Health Organization (WHO). Preparing for the introduction of HPV vac- This study has several limitations that should be noted. Due to cines: policy and programme guidance for countries. Geneva, Switzerland:the study’s exploratory nature, reported findings are descriptive in Author; 2006b. [2] Nelson JA, Francis SA, Liverpool J, Soogun S, Mofammere N. Healers in a non-nature. Also, given the non-random nature of participant selection, traditional role: a focus group analysis of the Sangomas’ view of cervical cancerour findings are not generalizable to all women. Although twenty- knowledge, attitudes and the HPV vaccine in Johannesburg, South Africa. Sexfour women participated in the three focus groups, we believe we Reprod Healthcare 2010;1(4):195–6, doi:10.1016/j.srhc.2010.07.004.reached the point of saturation, as no new themes or ideas were [3] Francis SA, Nelson JA, Liverpool J, Soogun S, Mofammere N, Thorpe Jr RJ. Examin- ing attitudes and knowledge about HPV and cervical cancer risk among femalegenerated. As is usual in focus groups, some participants were clinic attendees in Johannesburg, South Africa. Vaccine 2010;28(50):8026–32,more vocal than others. These focus groups were not unique in this doi:10.1016/j.vaccine.2010.08.090.regard. Although we found that in each of the groups many partici- [4] McFarland DM. Cervical cancer and Pap smear screening in Botswana: knowl- edge and perceptions. Int Nurs Rev 2003;50:167–75.pants were content to defer to others in the group, we hypothesize [5] Dailard C. HPV in the United States and developing nations: a problem ofthat this may be the effect of cultural socialization. We acknowledge public health or politics? The Guttmacher Report on Public Policy 2003;6(3that participants’ responses may have been influenced by the group (August)):4–6.discussion or by the more vocal participants. However, we tried [6] Katz ML, Reiter PL, Heaner S, Ruffin MT, Post DM, Paskett ED. Accep- tance of the HPV vaccine among women, parents, community leaders,to encourage quieter participants to share their thoughts by using and healthcare providers in Ohio Appalachia. Vaccine 2009;27(30):3945–52,“push and pull” techniques. We also recognize that the women may doi:10.1016/j.vaccine.2009.04.040.have attended the focus groups for a variety of reasons; for exam- [7] Harries J, Moodley J, Barone MA, Mall S, Sinanovic E. Preparing for HPV vaccina- tion in South Africa: key challenges and opinions. Vaccine 2009;27(1):38–44.ple, some women may have attended because they wanted their [8] Vijayaraghavan A, Efrusy M, Lindeque G, Dreyer G, Santas C. Cost effective-voices to be heard, while others may have attended to get the small ness of high-risk HPV DNA testing for cervical cancer screening in South Africa.stipend. Gynecol Oncol 2008;112(2):377–83, doi:10.1016/j.ygyno.2008.08.030. Given its limitations, the study has several notable strengths. [9] WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Human papillomavirus and related cancers in South Africa: summaryFirst, there is strength in exploring participants’ voices in such report update. 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